Off the Cuff: Public Health Shortchanged

Photo of Mary T. Bassett
© David Beyda

Why does public health in the U.S. receive such scant government funding and support, compared with what it receives in other countries?

By Mary Travis Bassett
Director of the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University; Former Commissioner of the New York City Department of Health and Mental Hygiene

The country’s public health expenditures are projected to fall to 2.4 percent of total health expenditures by 2023, putting us embarrassingly behind our peers. One of the reasons public health receives so little government funding in the U.S. is that its success is often invisible. Having clean air to breathe and safe water to drink are things we’ve come to expect in our daily lives. People are far more likely to notice our failures than our successes. Another problem is that public health is principally public sector spending, and the public sector is under real attack. Public health is also primarily a state function that depends on a regulatory framework guided by public health laws, and regulatory approaches are likewise under siege.

Public health was also born in an era of infectious diseases. And while it’s true that both new and old infections keep rearing their heads—HIV/AIDS, Zika virus, Legionnaires’ disease, Ebola—the leading causes of death today are noncommunicable diseases. This country generally sees the root causes of these diseases as bad choices made by individuals. So there’s not a great deal of confidence that public health can tackle these conditions. There is an unwillingness to view the leading causes of death as amenable to the tools of the government. All this makes it hard for public health to be as effective as it should be.

The strongest argument that public health can make for itself is that it saves lives. I think that’s the right argument to make. Arguments that public health is more cost-effective or efficient—these managerial arguments—are less compelling. What the public wants from us is protection—and that’s what the public can get if public health is allowed to exercise the tools that it has.

Public health works. It’s responsible for the huge advances in the health of the population over the 20th century. But historically, politics and public health have walked in step with each other, and that makes the case for public health more difficult in times like these. What I’ve learned over my career is how important it is for leaders to take risks and to spend not just money but political capital to advance public health action.