2.9: Challenges within the Public Health System
- Page ID
- 116087
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)There are many different challenges facing the public health system now. On this page, we examine just a few.
Rapid reorganization
As discussed below, in 2025 a major reorganization of public health organizational structures in the federal Dept. of Health and Human Services (HHS) as well as changes to funding for public health (with major and sometimes haphazard cuts to budgets) have resulted in considerable uncertainty. While these changes are taking place at the federal level, they impact the work of state and local health departments, as well. Changes in regulations, in funding streams, in program focus, and in data collection will have long-term effects on the public health system at all levels.
Optional: Want to hear an analysis of the impact of the first 100 days of the Trump Administration on public health? This podcast from KFF Health News offers an informed take: 100 Days of Health Policy Upheaval
Challenges of decentralization
On the previous page we discussed some of the challenges and advantages of a decentralized public health system.
This has been an issue even when public health is responding well to a crisis -- it often isn't perfect. Here is something I wrote about the CDC as the acute phase of the covid pandemic was wrapping up:
Two things about the US public health system's response to covid are true at the same time:
- Public health agencies made heroic efforts to slow the spread of disease, attend to populations in need, promote prevention, support the development and deployment of vaccines, and make sense of a fast-moving and unprecedented crisis, despite coming under serious attack from movements opposed to public health measures (attacks that have included death threats and violence toward some public health workers).
- Public health agencies have been poorly coordinated in their response, have issued confusing and sometimes contradictory messages to the public about how to stay safe, and were very slow to turn information into action, in several key moments.
Underfunding
When a major public health crisis emerges -- such as the covid pandemic that began near the end of 2019, or anthrax attacks that followed the attacks of September 11, 2001 -- Congress has typically increased funding to public health. It takes a great deal of resources to respond to a broad threat to health. However, between crises, the funding often shrinks back to minimal levels. On a per capita basis, public health agencies receive less funding now than they did 20 years ago. As we saw in Chapter 1, public health's successes are often out of the public's eye -- bad events that got prevented and never happened. The Trust for America's Health issued a 2024 report showing that core public health functions were significantly underfunded, even as the population grows and the threats to health multiply. This shortage of funding has only been magnified by the significant 2025 cuts to public health infrastructure, cuts of over one-third of all funding to the Department of Health and Human Services, including cuts of over 20,000 workers. While there is no doubt that any large agency could be made more efficient and effective with some well-planned reorganization, the rapid and severe cuts implemented in 2025 are likely to make the agencies less efficient and effective, not more so.
Trust and communication
Public health agencies have too often communicated with the public in a way that doesn't connect. Instead of providing clear guidance, we offer too much context. Or we err in the other direction, coming across as mandating actions without providing clear reasons for those actions. Sometimes we offer nuanced explanations with too much jargon, leaving everyone confused. The breakdown of communications from public health entities to the public has contributed to a breakdown in trust among a significant portion of the American public.
Without public trust, public health cannot do its job successfully. It doesn't help that misinformation and even disinformation has been generated to fill the gap, as more and more people turn to nontraditional sources for their health information. And in recent months, vaccine skeptics and others have taken major roles in the very public health agencies that, traditionally, have provided science-based answers. It is unclear what this will mean for science-based decision-making in the future.
Science is always evolving
The evolving nature of science means that public health agencies are sometimes forced to act on incomplete knowledge. Research takes time. New results or new information takes time to be thoroughly checked out before it is considered proven. The gap between what we know and what we need to know is even greater during a public health emergency. Many people were frustrated with changing advice during the covid pandemic, for example. Masks needed or not? How much distance is needed for social distancing? What about washing off our groceries? If you lived through the early years of covid, you know that it was often confusing!
But simply because the science was changing doesn't mean that the public health advice was based on nothing. It was based on the evolving science that helped us to understand a brand-new virus. For example, it was pretty quickly shown in the lab that the virus could linger on surfaces for some time, and that's why we were washing off our groceries and worrying about touching banisters. But it took a little longer to show that, while this was a theoretical risk, in practice, that was NOT how people were catching covid. The covid virus was being transmitted through the droplets (emitted when we talk, sing, or cough) and by aerosols that linger in the air longer. Understanding droplet transmission led to social distancing recommendations, and understanding aerosol transmission highlighted the need for good ventilation. Public health had to respond before all the research was done, leading sometimes to mistakes yet still, overall, to a huge impact on people's health. Social distancing and other public health measures are credited with saving upwards of 860,000 lives in the US in the first six months of the covid pandemic, alone (Yakusheva, et al., 2022).
References
Trust for America's Health. (2024). The Impact of Chronic Underfunding on America’s Public Health System 2024: Trends, Risks, and Recommendations. https://www.tfah.org/report-details/funding-2024/
Yakusheva O, van den Broek-Altenburg E, Brekke G, Atherly A (2022) Lives saved and lost in the first six month of the US COVID-19 pandemic: A retrospective cost-benefit analysis. PLoS ONE 17(1): e0261759. https://doi.org/10.1371/journal.pone.026175