In October of 2015, Bill Gates, the founder of Microsoft and one of the world’s richest men, stood in front of an audience at TED and delivered a harrowing message: We are not prepared for the next global outbreak. Today, as COVID-19 ravages our nation, we now know that he was right, and more importantly, nothing was done about it. The United States remains woefully unprepared to handle this global health crisis. Even with the firsthand lessons that 2020 has provided us, this status is unlikely to change. Unless we expand our definition of public health and recognize the value of investing in it, the next global health crisis will be just as disastrous.
The spread of Covid-19 has revealed the multitude of ways that the US’s public health infrastructure falls short. First, the emphasis placed on our ability to treat the disease often means that preventative measures are considered secondary options despite their broader reach and impact. This dynamic is not unique to the current pandemic; it has been a detriment to the health of Americans across the decades. It has left us particularly vulnerable to a disease that preys upon those whom our prevention efforts have already failed.
Next, even when preventative programs are enacted, their effectiveness is hampered by extreme levels of social inequity. A vaccine with almost 100% effectiveness would be incapable of eliminating a disease if it cannot reach people, for example, living on a reservation or in the hills of Appalachia. The two most promising vaccines – Pfizer and Moderna – both need to be transported in freezing temperatures, which pose significant logistical challenges when vaccinating an entire nation. While our success with the polio vaccine shows that these barriers can be overcome, the more practical route requires an investment in the human capital and public health infrastructure in these areas that would save us this hassle during future disease outbreaks.
Finally, the US definition of public health is too narrow. Vaccination and childhood nutrition programs are essential, but these interventions alone are insufficient for creating a robust public health infrastructure. For example, a person’s lifelong health history is closely associated with their experience of adverse childhood experiences or ACEs, which are affected by conditions related to education, employment, and criminal justice. Accordingly, our conception of public health and the corresponding efforts to improve it will continue to be incomplete until considerations related to these topics are included. Minority populations, in particular, experience a far greater rate of adverse childhood experiences, which corresponds with real-world implications. Academic research and exhaustive investigative reporting have shown that being a minority in America can be hazardous to one’s health. In Baltimore, for example, the life-expectancy gap between African Americans and whites is roughly 20 years as of 2018. Still, throughout 2020, the argument has continued to dichotomize support for the economy and support public health efforts without the recognition that they are critical and interlinking parts of the same chain.
A comparison with other developed nations reveals the extent to which the United States has failed to prioritize public health. The US has the highest per capita spending on healthcare expenditures. Despite this fact, residents in the US do not see a corresponding increase in their health-related quality of life. Yet, even with health-related expenses at their highest levels ever, there has not been a corresponding elevation of public health spending. As the price tag for health and healthcare in the US has climbed dramatically, the proportion of healthcare spending directed toward public health endeavors continues to decline. The US already spends less on public health due to its total health spending compared to other developed nations. Conversely, other countries spend far more money on proactive healthcare. In other words, they spent money on keeping their citizens healthy rather than treating their illnesses once they get an ailment. This sort of proactive healthcare spending pays for itself in the long term.
It may seem paradoxical, but increased public health spending can and should be part of a fiscally conservative model of government. Investments in public health lead to greater returns than investment in medical technologies alone. Based on a systematic review of more than 20 studies, researchers estimate an overall median of $14.1 returns for every $1 spent on public health. By preventing the development and mitigating the harms of a wide range of medical conditions – from addiction to diabetes to cancer – the US would see an increase in economic productivity and decrease tertiary healthcare expenditure. This approach also benefits an average family unit, directly translating into an improved quality of life for future generations.
From this perspective, public health spending is an investment in US society that other forms of government spending struggle to match. Though the specific programs and initiatives that should receive extra support go well beyond this article’s scope, this vital discussion can no longer wait. Many politicians, particularly from the Republican camp, stymie further healthcare investment by merely slapping on the ‘socialism’ label and leaving the conversation as if this dirty word should negate further discussion. Yet society-at-large almost unanimously acknowledges the importance of socialized fire departments, road construction, and education because we recognize the broader impact of these types of spending on society’s ability to function. It also means recognizing the intersectionality of economic, judicial, and social interests with public health. If we continue down this road, the US will continue to have higher mortality rates and more consequences compared to other nations of similar levels of development.