Securing the Future of Public Health through Advocacy of the Public Health Economy

By Christopher Williams
Founder, Public Health Liberation

I recently received an action alert from a prominent medical education organization calling for increased federal funding for physician training programs. Addressing a shortage of up to 124,000 physicians in ten years will ensure access to patient care and readiness for the next public health crisis, claimed the organization. [1] This email prompted several critical reflections. First, their efforts can be understood as public health leadership. Hospital and physician organizations have a longstanding role in public health agenda-setting. Second, the extent of the US physician shortage is widely debated. For over ten years, I served as a medical education researcher and knew that the major accreditor for training programs differed significantly in their assessment - unofficially at least. I recall that the CEO remarked at its international conference several years ago that the urgency of physician shortages was not in the pipeline, but in the geographic distribution of physicians and lack of mid-level providers. In other words, we do not need to increase the rate of physicians entering the workforce as much as address the conditions leading to regional disparities in health care availability due to consolidation, closing of hospitals, and profit-driven health care.[2] “While only 14 percent of Americans—almost 46 million people—live in rural areas, rural communities represent nearly two-thirds of primary care health professional shortage areas (HPSAs) in the country.” [3] I also knew that the accreditor was prevented from political advocacy, unlike many major organizations in this space, because of limitations within its congressional authorization. Many medical education, hospital, and physician organizations encouraged the bipartisan laws in 2020 and 2022 that provide Medicare support for 1,200 residency positions. This new push is seeking to build on their prior legislative success.

While they assert public health leadership, there is an existential crisis at the Centers for Disease Control and Prevention (CDC) and in public health broadly - my second reflection. Notwithstanding the accreditor’s position, the coalition of hospital and medical education interest groups acted decisively during the Covid pandemic. In sharp contrast, public health is under increasing scrutiny and legislative oversight. Former CDC directors questioned its mission and capability in 2022. A full discussion appears here. Former director Robert Redfield explained, “I always thought it was bothersome that the data the nation used to track the epidemic was from a medical school rather than CDC. So I do think there's an enormous need for CDC to be the hub of a public health data modernization.” [4] Former CDC Director Bill Roper questioned whether the mission of the CDC is clear, “But one of the most important things to get clarified with regard to CDC is, what is its mission?” [4] By its own admission, the CDC faces “structural and systemic operational challenges, which were exacerbated during the COVID-19 pandemic…(S)ince the pandemic, we also acknowledge that the CDC is responsible for some large, public mistakes.” The federal face of public health in the United States is adrift. That has consequences for all those within public health research and advocacy because it is the relevance and efficiency of our field that are called into question. A major determinant of our fate depends on whether the CDC can effectively restructure and regain the political and public trust. It cannot do so without a clear mission, adequate resources, and a pivot around the Public Health Economy.

The third and final reflection is that the analytical lens of the Public Health Economy - a soft and hard science - would benefit public health. As we stated in our inaugural manuscript, “Through ongoing surveillance of the Public Health Economy, it enables PHL practitioners to identify opportunities to interrupt harm and to quickly marshal resources for legal, social, and political intervention.” [5] The Public Health Economy most needs a common defense wherein public health pivots around values, theories, practice, research, and training to accelerate health equity. The state of public health is characterized by hyper-competition and fragmentation without the benefit of a clear mission or theory. “Public health has yet to evolve a transdiscipline capable of 1) creating a theory that explains persistent health disparities, 2) establishing consistent techniques to respond to the complexity of economic, political, and social influences in the public health economy…”.[4] Another explanation for fierce competition is due to vast underinvestment in public health in the US. “So, we're basically operating a CDC in a public health system right now that's funded on a per capita basis less than it was in the 1950s in real dollars,” explained former CDC Director Gerberding.[4] It is in the interest of public health to defend its value and need for funding.

Insight into the Public Health Economy - both macro and micro - would best position public health to secure its future. This approach would account for the social, political, and economic determinants that vary across PH economies. “Changes in contextual factors within the public health economy have major implications for the generalizability and reproducibility of research. Health equity research is valuable insofar as studies can be reproduced and can assume that unmeasured variables, including external influences, do not confound the study,” as stated in our inaugural manuscript.[6] Public health would benefit by accepting political realities - what works in Texas may not work in Massachusetts. Absent new federal laws and authority, pathways to health equity look differently at the level of the Public Health micro-Economy, meaning the local and state levels. Federalism means that states wield immense power in public health advancement. It is in public health’s interests to level with this political fact.

The Public Health Economy can open a new field of study for public health, making it more relevant to health equity challenges across disparate communities. To our understanding, there is no formal training program that seeks an interdisciplinary and seismic transformation of public health to draw upon other fields to elucidate and affect the Public Health Economy under a single disciplinary umbrella. The moment for public health is now. If the CDC is any indication of the state of public health, deep fragmentation and inefficiencies will cede public health expertise and health equity discourse. Physicians and their affiliate organizations such as membership groups and hospitals may very well lead the public health agenda.