Public health in US midterm elections

Health a neglected topic

Yet overall, public health represented only a small portion of the priorities identified by voters at the polls. Only 7% of voters identified healthcare as the most important issue facing the country.2 Only 2% said it was the covid-19 pandemic, even though the US performed poorly among wealthy nations in cases, deaths, and vaccinations. Over the past two years, American life expectancy dropped by 2.7 years, the largest decline in a century; nested within that statistic are devastating disparities, with a drop of 4 years, 4.2 years, and 6.6 years for Black, Hispanic, and Native Americans, respectively.8 Addressing such grave failures, losses, and inequities requires galvanising around a robust public health infrastructure. Instead, we risk continuing our decades of disinterest and disinvestment in public health.

Michelle Williams, dean of Harvard T H Chan School of Public Health, has said politicians need training in public health “to really understand the primacy of public health in the national security and the economic security of the constituencies that they serve.”9 The message of primacy of public health has been lost for quite some time, and public health has suffered. Since 2010, per capita spending of state public health departments has dropped by 16% and spending for local health departments has fallen by 18%. At least 38 000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce.10In the state of Missouri, public health spending is only $7 (£6; €7) per person.11 Meanwhile, the remit of public health agencies is vast, encompassing innumerable essential roles needed to promote health, respond to acute health emergencies, prevent chronic diseases, and ensure receipt of health services.

Public health underpins everything

Americans often mobilise around public health through singular, monolithic issues. But wins in flashpoint issues depend on a strong public health foundation. For example, gaining universal abortion rights may be a hollow victory in the absence of equitable and accessible women’s health services across diverse communities. Funding streams through local health departments ensure access to safe abortion services, health education, preventive health measures, and routine reproductive healthcare.

Public health is also present in our desire to build a strong economy and jobs. Economic growth, high productivity at work, and participation in the workforce are fully enabled when people are healthy and well, and we make them so with a public health infrastructure that is equipped to support the structural determinants of health. We do not disagree that the economy and jobs, abortion, and gun violence are the most pressing concerns facing our country. But the role that the public health system has on these priorities has been lost.

Health professionals and elected leaders need to raise visibility and societal literacy around the role of public health as a vital partner to our security and prosperity. They must lead with vision about what a powerful, responsive, and well funded public health system would mean,12 including fortified emergency preparedness for emerging health threats; world class disease surveillance and laboratory capacities; data systems structured to detect health inequities and linked to action; a culturally diverse public health workforce, well equipped to provide the broad range of services needed and sustained by liveable wages; and expertise in clear and effective health messaging that builds trust within communities. They must define minimum thresholds for per capita public health funding and standardise public health systems to ensure that every community is assured of fundamental public health services. And they must be clear about how investments in public health have large, meaningful returns on health and quality of life.13

When given the opportunity, US voters chose health. We need to give them more and better opportunities to do so, through candidates and ballot measures that envision what a bedrock of public health might offer us as a society.