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Better late than never - my thread on the US public health (PH) system.

This doesn't cover everything, but does provide an outline of how funding & structures work with each other.


We learn in public health school that all public health is local.

We've seen this in how the pandemic has played out. Local factors, local leadership has mattered so so much in this.

Local health jurisdictions (LHJ) are tasked with delivering programs & services to protect the public from infectious (flu, TB, Syphilis) & chronic (cancer, diabetes) disease & environmental (e.g., lead) threats.

Wonder how flu shots are free/low-cost? PH $$ at work!

How are these local PH programs funded? A combo of local, state, & federal taxpayer dollars.

This is where the bulk of CDC funding goes because the US has a decentralized PH system.

LHJs take care of local needs, with assistance from state & feds, if requested.

LHJs set their own health priorities based on community needs.

Fargo (no offense) might have a multi-yr gonorrhea outbreak that requires $$$ spent on screening/testing/treatment to end, while while Atlanta might have a short-term Legionnaires outbreak that needs fewer $.

That's an acute event & not the bread & butter of public health, which is focused on disease surveillance & prevention.

Each LHJ gets CDC (& other federal funding) to collect, monitor, and analyze health data (aka surveillance). The state often acts as a conduit for fed $$.

How do we know what programs different communities need? Birth, health & death data.

Surveillance data like new HIV infections in adults & # of babies born with birth defects, allows LHJs to understand the scope of a PH problem.

PH Surveillance=core function of an LHJ!

What do LHJs do with the results of surveillance data?

Develop programs & services to improve or prevent the PH problem!

e.g., Food fortification of staples (like flour) with vitamins & nutrients (iron, zinc) helps to prevent birth defects & anemia in pregnant people.

Certain conditions (mostly infectious) are "notifiables" (required reporting).

Labs, private doctors & other healthcare facilities report these to LHJ ➡️State➡️ CDC.

There's a whole list, enjoy:…

...these are the same types of reporting & service delivery structures by which chronic disease $$ is allocated by CDC & other health focused agencies within HHS.

So why are we all up in arms about CDC's role in this pandemic so far?

Most people think of the CDC when they hear about outbreaks of E Coli or Salmonella, & dramatize it's most visible workers, the Epidemic Intelligence Service, in movies like Contagion (Kate's character)....where "shoe leather epidemiology" does much of the heavy lifting.

The core work of the CDC is not in outbreak investigation, as I hope you've seen in this thread.

Bulk of CDC efforts are focused on evaluating & applying science at the frontline by funding local (county, state, territory) programs including providing policies & guidelines.

"Controversial" opinion ahead: if you think health is not a human right, then you think health & public health is political.

CDC has politically appointed directors.

As an agency within a (political) cabinet department, it's subject to the whims of the Chief Executive.

This means national health priorities have to be championed by CDC leaders who will influence Cabinet Secretaries to fund the right things...

Satcher, Sencer, Foege & @DrTomFrieden have had significant civil service + credibility & influenced with some success.

In general, CDC directors are extremely dedicated civil servants & scientists that have the respect of their workforce of 11000+ policy analysts, program managers, public health advisors, epidemiologists, medical officers, & support staff.

CDC staff=excellent. 💯

Whatever you think of news media in this country, the investigative reporting by NYT& WaPo on CDC's sidelining have reassured many of us in public health that current CDC + HHS leadership is primarily to blame for the reduced stature of the agency.
CDC guidance is still useful when we have access to the unedited (cough*byHHS/White House*cough) version but from a leadership perspective, Redfield has not done right by his staff.

What happens when LHJs don't have guidance they can trust from CDC?

Confusion. Anxiety.

Some of us are lucky because we live in states (CA, NY, MA) + LHJs with lots of PH expertise (NYC, LAX) but other states don't have the same capacity.


LHJs get funding for specific disease work from CDC/federal agencies but it is meant to *supplement* state funding.

So if a state like N. Dakota doesn't invest in the infrastructure to tackle all their public health needs, the money coming from CDC is not enough to do the bulk of the work.

Since 2009, spending at state & LHJs have ⬇️ 16% & 18%, respectively!!…

The pandemic response we've seen is what happens when different local (healthcare, emergency, PH) systems are left to handle what should be a national response.

People like @JeremyKonyndyk & @ASlavitt refer to an Obama era pandemic playbook:…

But if there isn't a staffed pandemic response team at the top with knowledge & experience to lead the effort, what good is the playbook?

We saw this play out re: schools this week. Media focused on the language on the landing page, which was 👎🏾.…
But the guidance didn't get much attention; early July WH shenanigans delayed it's release.

Meanwhile local school systems had to rely on their LHJs to help them figure out what to do. The effect? Confusion & debate about whether reopening is safe.

For school administrators working on whether and how to reopen schools, the guidance provides questions, indicators, and other considerations to be aware of.

Short answer: where there is significant community transmission (large swathes of the US) reopening is not advised.

If we had an actual national pandemic response, we wouldn't even have to worry at this level.

Most parts of the US are experiencing significant delays in test results (because no supplies, lol), which makes contact tracing difficult (if not near impossible to do).

I feel I've gotten off track I'm going to pause for right now.
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