Shrinking public health budgets shrink public health responses

Across the country, more than 55,000 positions were eliminated from local health departments — our front-line defenders — between 2008 and 2017.

A bottle of hand sanitizer sits in front of reporters as Governor Jay Inslee gives updates on Covid-19 cases in Washington state on Monday in Olympia.Amanda Snyder/Associated Press

With a frightening new coronavirus spreading across the globe; life expectancy in the United States on a downward slope; antibiotic resistance undermining modern medicine; and cancer poised to become the leading cause of death nationally, this is no time to drastically shrink public health funding. Yet President Trump’s proposed fiscal 2021 budget for the Centers for Disease Control and Prevention — the nation’s flagship public health agency — does just that.

The proposed budget is $707,981,000 less than the fiscal 2020 CDC budget — a reduction of just over 10 percent. This comes on the heels of a long decline in funding. While Congress increased last year’s CDC allotment by $636.8 million over the 2019 figure, it was too little too late. Between 2010 and 2019, the agency’s budget fell by 10 percent, adjusting for inflation. Meanwhile, across the country, more than 55,000 positions were eliminated from local health departments — our front-line defenders — between 2008 and 2017.

These fiscal constraints are happening at a time of overlapping public health crises. While the CDC in January reported a slight rise in US life expectancy — to 78.7 years in 2018 from 78.6 years in 2017— that uptick belies a broader and more discouraging trend. According to a study this past November in the Journal of the American Medical Association, beginning in 2014, US life expectancy declined for three years in a row. That’s a stunning turnaround; over the previous 60 years, Americans’ life expectancy had been steadily on the rise.

Against this backdrop, many of the proposed CDC cuts make little sense. The budget for chronic disease prevention and health promotion, for example, takes a walloping $426.7 million hit — even though most of the top 10 causes of death in the United States are chronic afflictions, with heart disease and cancer leading the pack, and stroke, Alzheimer’s disease, diabetes, and kidney disease not far behind. Many — including heart disease, cancer, and diabetes — are highly preventable through lifestyle changes, early detection, and education: the essence of public health.

The CDC’s program for emerging and zoonotic infectious diseases — infections caused by germs passed between animals and humans, such as Ebola and West Nile viruses — loses $85.3 million in the proposed budget. This means less money for research and interventions on novel infections like Covid-19, the deadly new coronavirus; food safety; and antibiotic-resistant infections, which strike some 2.8 million Americans yearly and kill 35,000, according to a CDC report issued last November. While the proposed $50 million increase in global health security is a wise investment, since local epidemics regularly vault borders, it only partly offsets the larger cut.

The proposed budget also axes $57.5 million from the CDC’s public health scientific services, which include the very programs — such as the National Center for Health Statistics — that objectively quantify our country’s disease rates and trends. A public health axiom holds that we can’t manage what we can’t measure. The proposed budget also trims the CDC’s activities in public health preparedness and response by $25.2 million.

Skimping on public health is disastrously myopic. When Americans are healthier, medical costs decline and job productivity goes up. In 2017, the Journal of Epidemiology and Public Health published a systematic review of the return on investment of public health interventions in high-income countries — including the United States. It found a median return on investment of 14 to 1.

Sadly, public health has been chronically shortchanged — in part because when it’s successful, it’s invisible. That’s what Harvey V. Fineberg, former president of the Institute of Medicine (now the National Academy of Medicine) wrote in a now-iconic 2013 article titled “The Paradox of Prevention.” We expect to have clean air to breathe and safe water to drink — two vital public health responsibilities — and only notice those when they’re missing. We are moved when a disease is cured but not when that disease is prevented — because it’s a plotline where nothing happens. We know when public health is successful from statistics, not from personal stories — and whether in newspapers or on social media, statistics do not make an emotionally compelling argument.

It hasn’t always been this way. In the early 20th century, a visionary physician named Hermann Biggs revolutionized New York City’s health department and, later, as its health commissioner, New York state’s. Biggs had an expansive view of public health and deployed all of that era’s cutting-edge tools — laboratory science, education, and strong public health laws. As a result, deaths from such lethal scourges as tuberculosis, diphtheria, cholera, and typhus plummeted. It was Biggs who coined one of our profession’s most cherished mottos: “Public health is purchasable. Within natural limitations, a community can determine its own death rate.”

Public health is purchasable. And it’s the best bargain around. The CDC deserves robust and sustained funding for all of its life-saving work. Especially now as the nation ramps up to contend with coronavirus — and in the future when health officials can return their primary focus to preventive public health measures that are proven to save lives. Perhaps even yours.

Michelle A. Williams is dean of the Harvard T.H. Chan School of Public Health.