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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
January 5, 2021
Building Back Better
Sandro Galea Read Bio
Lawrence O. Gostin
Alan B. Cohen
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The arrival of the first COVID-19 vaccines and of new Presidential leadership mark important turning points in the pandemic. President-elect Biden announced Rochelle Walensky, an infectious disease expert, as his nominee for CDC director, and policymakers are turning their attention to revitalizing the Centers for Disease Control and Prevention (CDC) as well as the nation’s public health system at the state/tribal/local level. While a comprehensive blueprint for public health reform will take time, we outline eight key operational steps to revitalize the CDC. CDC’s renewal is imperative after a suboptimal performance during the pandemic, while also being politically undermined by the Trump administration.
The Biden administration should identify strategies to protect the CDC’s—and other scientific agencies’—scientific integrity, shielding the agency from being politically attacked or sidelined. The Trump administration has discredited and undercut the CDC, the Food and Drug Administration (FDA), and the Environmental Protection Agency (EPA). Unrelenting pressure to align a scientific agenda with political expediency and ideology have challenged these agencies’ capacity to act on the best science, in the public interest, and have eroded public confidence in their guidance. Mechanisms that typically help protect scientific integrity, such as external scientific advisory committees were disbanded or never convened, suggesting the need for additional mechanisms to safeguard the independence of these agencies. The CDC, perhaps in concert with other science agencies, could commission the National Academies of Science, Engineering and Medicine to formally study events over the last four years, and to develop a comprehensive set of recommended safeguards. Effective safeguards should ensure that going forward, scientists can use their best scientific judgment to inform the public about health threats and how to mitigate them. This will require a set of actions, as no single approach will be sufficient. Just as targeted, layered interventions are needed to end the pandemic, a related set of targeted, layered protective measures are needed, along with early warning systems that can activate other components of such a protective system.
There is a substantial and urgent need to streamline and modernize the data systems at the CDC and throughout the nation’s public health agencies, to create a seamless national health data ecosystem. This requires modernization of data collection and data analytics. We must end the needless separation of population health and health care data. The CDC collects health care system data in silos, for example hospital acquired infections and syndromic surveillance from emergency departments. Data from the health care system is not comprehensively leveraged to identify or monitor public health threats. A comprehensive system of data collection that captures de-identified information from claims data and Electronic Health Records (EHR) could allow for real-time data monitoring, hot-spotting, and the early identification of disease. Integrated data systems would safeguard the public’s health far better than we do currently. The CDC, in collaboration with the Centers for Medicare & Medicaid Services (CMS), could begin monitoring these almost immediately for the Medicare population, adding additional data partners over the next few years. Streamlined data systems (a widely recognized need) are necessary but insufficient to monitor and analyze multiple streams. Machine learning and artificial intelligence (AI) are being deployed in multiple sectors, from national and cyber security to genomic surveillance, the internet, and sales or marketing. The Department of Defense, among others, is investing heavily in AI. The CDC, for example, should set up a national system to link viral sequence databases with on-the-ground data to surveil and respond to currently circulating SARS-CoV2 variants, which could become resistant to vaccines.
The CDC, with additional appropriations, should invest in modern technologies, while sharing know-how and offering technical guidance to state, tribal, local, and territorial partners. Advanced technologies would free epidemiologists and other public health scientists to interpret and act on the data, rather than hunt for signals. Public health interventions that leverage such data are highly cost-effective, with savings accruing to the health care system, including to taxpayer-funded Medicare and Medicaid programs.
The CDC has been the pre-eminent public health agency for decades because it has employed the best public health workforce in the world. But the world’s needs are changing, and the CDC’s workforce needs to change accordingly. While the traditional approach to disease surveillance, pioneered by its Epidemic Intelligence Service (EIS), remains a foundational bedrock for all CDC activities, these skills need to be complemented by expertise in mathematical modeling, systems and data science, high-end laboratory methods, and “omics” (collective characterization and quantification of pools of biological molecules that translate into the structure, function, and dynamics of organisms). Such skills are vital for rapid disease detection and monitoring in the modern world. Even a major investment in sophisticated analytic approaches will never be sufficient unless CDC staff are grounded in the realities of disease control and prevention across a big country. One could imagine a plan to place certain CDC staff on a three-month rotation through a state/tribal/local health department, a health care system, or other public health-oriented public- or private-sector organization at least once every five years. This would strengthen relationships between the CDC and public health departments, providing opportunities for improved bidirectional awareness and collaboration. If done thoughtfully, such a program could have the indirect benefit of helping members of Congress understand the direct benefits of CDC partnerships in their jurisdictions.
The national system of public health services is highly reliant on public health officers at the state, tribal, and local levels. This system has long been fragmented and understaffed. The Association of Schools and Programs of Public Health has estimated that we need 250,000 more public health workers to cover national needs. COVID-19 revealed the limitations of the nation’s public health system. Nearly 200 local and state public health department leaders resigned, retired, or were fired during the pandemic, further straining human resource capacity across the country. In the past five years there has been a more than 40% increase in the proportion of the public health workforce planning to leave their jobs. While there are no data yet, we expect an exodus from public health jobs in 2021 and beyond, as local and state officers, burned out on an unprecedented year of COVID-19, move on to greener pastures. The CDC needs to be an advocate for the public health work force, validating the need for greater recognition, fair pay, and hiring and retention systems that can ensure the nation has a highly skilled public health workforce for the nation’s vital health needs, ranging from emergency response to health protection and promotion in non-emergency times.
The CDC is uniquely placed to shape the country’s health priorities. There has never been a more important moment to put health equity at the heart of all health actions. This would require a reorientation of the CDC’s surveillance, reporting, and response capabilities. Disaggregated data that capture and characterize race and ethnicity, gender, age, disability, and other granular geographic/socioeconomic identifiers are essential to respond to health disparities. These data can be linked to the Social Vulnerability Index or similar measures, so that data are all reported overall and by subgroup and area level social vulnerability to ensure that health equity is prioritized together with efficiency. The COVID-19 pandemic showed us clearly the limitations of our current capacity to track equity data. For example, the COVID-19 Racial Data Tracker found that only a handful of states nationwide had adequate data collection of racial/ethnic information for COVID-19 cases. By taking a strong stance, the CDC’s commitment to tracking data that allows us to elevate the priorities of health equity would be transformative across the country. It also provides tools to ensure that programmatic funding for public health interventions actually make it to the areas of most need.
While both the World Health Organization and the US Department of Health and Human Services have stressed the importance of health-in-all-policies (or an all-of-government or all-of-society), advocacy and policies are often abstract. We need clear operational direction that can make this vision a reality. The CDC stands to truly embrace this approach through comprehensive engagement with policy making at every level. One potential strategy could be the placement of a senior public health scientist in every major cabinet office, as an effort to ensure that health is at the table for the creation of all policies, be they environmental, energy, food and agriculture, financial, housing, transportation, or other sectors. This would also have the advantage of elevating the visibility of the agency, further protecting it from budget cuts and political pressure. We note that private sector policies of appointing Chief Public Health Officers in many large companies shows a post-COVID-19 appetite for injection of public health science into non-traditional settings, creating a moment-in-time opportunity for the CDC.
Public health in the United States has been systematically, and increasingly, underfunded over the past several decades. For example, per capita spending for state and local public health departments has decreased more than 15% since 2010, and more than 50,000 public health jobs in state, local, and territorial public health departments have been lost since the 2008 great recession. Fundamentally, none of the action plans we propose here are possible without robust funding for CDC and state/tribal/local health agencies. Greater federal appropriation of resources to the CDC and to devolved public health agencies is a sine qua non of any major step forward. In addition to public funding, one can imagine creative approaches increasing public health resources, including, for example a small surtax on every health or disability insurance premium to help fund public health. A healthier population would benefit both health insurers and health providers making it, to our minds, both rational and potentially politically feasible to ensure adequate funding of the CDC’s mission through mechanisms traditionally reserved for the financing of curative care. We could also consider adding a small tax surcharge on unhealthy activities, such as alcohol, tobacco, and/or sugary beverages. This would not simply raise funding for public health, but also contribute to a healthier population and reduced medical costs.
The United States has long been an outlier in health outcomes compared to peer countries, and even low-and middle-income countries. We know that we spend far more on health than do any OECD countries, and have, essentially, the worst health indicators. That this state of affairs is tolerated is astonishing, regrettable, and does little to engender confidence in the capacity of our health agencies—CDC included. A deeply embedded notion of American exceptionalism may explain our tolerance of enduring poor health, despite our extraordinary spending on health and prowess in scientific discovery. American exceptionalism may have, over decades, limited us from learning from other countries. COVID-19 may be a moment of opportunity to think differently. Can we learn, for example, from New Zealand’s Wellness Budget that prioritized health in all sectors? Can we learn from South Korea’s capacity to rapidly scale up testing and contact tracing within weeks of the identification of a novel coronavirus? Can we, as the country that has fared worst in the world during this global pandemic, be honest about our shortcomings and identify ways to create a healthier future? The CDC can lead this transformation in our national conversation, carefully studying ideas from across the globe, while adopting the most successful health strategies. Bringing the best ideas to America, and improving on them, can help to achieve a healthier and safer population.
We recognize that the incoming CDC Director has a monumental and deeply consequential task ahead of her. We applaud the new administration’s dedication to science and health, as well as salute the dedication and unrivalled expertise of CDC scientists. We offer these eight ideas to the agency’s leadership as conversation starters, towards our shared goal of strengthening the CDC for decades to come.
Sandro Galea, a physician, epidemiologist, and author, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. He has published extensively in the peer-reviewed literature, and is a regular contributor to a range of public media, about the social causes of health, mental health, and the consequences of trauma. He has been listed as one of the most widely cited scholars in the social sciences. He is chair of the board of the Association of Schools and Programs of Public Health and past president of the Society for Epidemiologic Research and of the Interdisciplinary Association for Population Health Science. He is an elected member of the National Academy of Medicine. Galea has received several lifetime achievement awards. Galea holds a medical degree from the University of Toronto, graduate degrees from Harvard University and Columbia University, and an honorary doctorate from the University of Glasgow.
Lawrence O. Gostin is University Professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.”
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
Nicole Lurie is Strategic Advisor and Response Lead at the Coalition for Epidemic Preparedness Innovations. She previously served an 8-year term as Assistant Secretary for Preparedness and Response at the US Department of Health and Human Services.
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