Reframing U.S. public health post-COVID-19

In the aftermath of the COVID-19 pandemic, the U.S. public health system must focus on critical questions of accountability, politicization and updating data systems if it is to do its job well and maintain the trust of the American people, according to a new report from the Colorado School of Public Health.

The report, authored by Professor Jonathan Samet, MD, MS, of the Colorado School of Public Health and Professor Ross Brownson, PhD, of Washington University in St. Louis, was published recently in the journal Health Affairs.

In it, the researchers detail the current shortcomings of the public health system, drawing on lessons learned from the COVID-19 pandemic, and some of the future challenges it's likely to face including climate change and retaining a well-educated, motivated workforce.

"As early as November 2020, we anticipated the need for `reimagining' public health in light of the pandemic," they wrote. "The past several years have made one thing clear: transformation of the U.S. public health system is needed, and needed now."

After interviewing a wide range of public health officers from across the country, the researchers focused on accountability, polarization, climate change, equity, data science, workforce improvement and communication to broader audiences.

"A transformed public health system will depend highly on leadership, funding incentives, and both bottom-up and top-down approaches," said Samet, former dean of the Colorado School of Public Health. "A broad effort is needed by public health agencies, governments, and academia to accelerate the transition to a next phase for public health."

One of the biggest challenges, he said, is politicization.

Trust in public health institutions eroded among many during the pandemic. People questioned vaccine mandates, social distancing, keeping kids out of school and the choices as to which businesses could open and which must shut. Some political leaders attacked science and public health officials, leading to threats of violence. Many quit their jobs.

"By its name and what it does, public health is by nature political," Samet said.

One solution may lay in using local leaders as messengers.

"A strategy using trusted local messengers, armed with the training and materials to educate communities on core public health issues, may also decrease the influence of polarization," Samet and Brownson wrote. "Locally familiar voices are more likely to be effective than national-level or state-level messengers."

Another critical shortcoming was the effective use of data.

Tracking the epidemic at the local, state, and national levels through government data systems was inadequate, largely thanks to the lack of an integrated and timely national system for critical morbidity and mortality data."

Professor Jonathan Samet, MD, MS, of the Colorado School of Public Health

He noted that in a time of `Big Data' harvesting and the speed of Artificial Intelligence, some public health offices still work with pencil and paper.

"But we anticipate the growing use of AI for dealing with large quantities of surveillance data and for data synthesis and visualization," the authors wrote. "AI will complement, but not replace, human data analysts, and there is still much to learn about its downsides when used in public health."

As for looming public health threats, Samet said climate change was among the biggest. Higher temperatures mean less food production, more migration, increases in certain kinds of diseases, toxic smoke from wildfires and displacement from fire and flooding.

"Projections of the burden that climate change will pose to human health have been made with the objective of motivating mitigation, although they have gotten little traction," the authors wrote.

Given the fragmented and limited authorities at the federal level and the local nature of climate-related health impacts, the public health system should play a major role in handling these issues, Samet said.

The Colorado School of Public Health (ColoradoSPH) now offers a PhD in climate and human health and the University of Colorado School of Medicine offers a diploma in climate medicine, one of the first in the country to do so.

Change won't be cheap nor fast but steady incremental change at the state and local level may be easier than waiting for federal action. During the pandemic, while Samet was dean of the Colorado School of Public Health, he won national prominence for modeling the path of the virus and by working closely with state agencies and the governor's office to help set health policy.

"Creative partnerships can magnify impacts," he said. "One promising approach is the academic health department, in which an academic institution partners with a governmental public health agency. These relationships can build workforce capacity, enhance the use of evidence-based interventions, share resources, and provide surge capacity during epidemics."

Colorado School of Public Health Dean Cathy Bradley, PhD, said she was pleased to see the school's faculty and staff working with national and international partners to shape the future of public health education and research.

"ColoradoSPH is committed to addressing many of the pressing issues detailed in the Health Affairs series Reimagining Public Health, and our team is strengthening the school's role as an indispensable public health thought-leader in Colorado and across the globe," she said.