Commentary: A Strong Public Health System: Essential for Health and Economic Progress

Public health has been defined as “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals” (1).

Public health, and not medical care, has been responsible for most of the health gains in the world during the past century. Public health initiatives such as clean water and sanitation, vaccination, tobacco control, motor vehicle and workplace safety, and improved nutrition led to 80% of the gain in U.S. life expectancy in the 20th century (2). Globally, public health accomplishments such as smallpox (3) and polio eradication (4), and immunization (5) have saved millions of lives.

The U.S. CDC, created in 1946, has become an epicenter of public health knowledge and practice (6-7). China CDC is a much younger organization, created in 2002. The following year, the SARS outbreak killed 774 people worldwide, including 349 in China. In response, China’s government made substantial investments to strengthen China CDC (8). I was privileged to serve as director of the U.S. CDC from 2009–2017, and have seen firsthand, through visits and regular communication, how dedicated China CDC leadership and staff are.

The most effective public health units at local, city, state/provincial, national, and global levels have at least 5 key components (7,9). These include:

Sufficient funding. The U.S CDC’s annual budget is more than U.S. $12 billion (10), which is nearly U.S. $40 per person.

Sufficient number and quality of staff to detect, investigate, stop, and prevent health threats, including robust laboratory and disease investigation capacity. The U.S. CDC has approximately 14,000 regular full-time staff and another 10,000 contract staff focused on all aspects of health promotion and disease prevention, from infectious diseases and environmental health to noncommunicable diseases and injuries (Table 1). In virtually any area of health, some of the world’s top experts are working at the U.S. CDC. In addition, in the United States, state, city, and local public health agencies employ more than 200,000 additional people. Furthermore, the U.S. CDC is able to pay top health experts competitive salaries above the standard government pay scale (11).

Close connections with other public health and health care entities. The U.S. CDC sends billions of dollars a year – 60% of its budget – to state and city health departments to assist with specific programs. These are in the form of “cooperative agreements” and include specific requirements for the local area and commitments of the U.S. CDC. U.S. CDC also sends 1,000 staff to embed with state, city, and local health departments for periods of 2 years or more. These local agencies have a wide range of capacities, some on par or superior to those at U.S. CDC, and others which need extensive technical and financial support. The essential importance of the U.S. CDC has been not just providing reference and technical leadership, but also upgrading skills and capacities of state and local public health, where competence can determine whether an emerging health threat is found and stopped rapidly.

Technical independence in the context of political support. The U.S. CDC is a federal agency just two steps removed from the President, with considerable latitude to act independently. CDC’s technical expertise is respected both within and outside of government, both in the U.S. and globally. As U.S. CDC director, I briefed President Barack Obama on critical health issues. This direct access to the highest level of government gives U.S. CDC authority and ensures that public health is prioritized at a national level.

Effective communication. The U.S. CDC communicates frequently and effectively with the public, doctors, the media, and policy-makers. It produces the MMWR, a weekly epidemiological digest widely respected as a definitive resource worldwide. In times of crisis, it follows the risk communication principle: “Be first, be right, be credible”.

China has a history of excellent public health practice. The country has reduced maternal and infant mortality rates and improved life expectancy over the past half century (12). There has been great progress controlling and even eliminating many formerly endemic infectious diseases (13). China faces new challenges with the emergence of new infectious diseases such as COVID-19, increasing antimicrobial resistance worldwide, and the increase in noncommunicable diseases, driven in part by high smoking rates among men, high sodium consumption, and air pollution (14). The Healthy China 2030 policy established a plan to achieve the UN Sustainable Development Goals (SDGs) and address these important health issues (15).

Epidemic prevention and control requires both hard work and deep expertise. Infectious disease cases need to be detected, investigated, treated, and monitored, with contacts traced and checked and epidemiological trends analyzed to identify prevention strategies. Every country needs capacity to prevent, detect, and effectively respond to disease outbreaks – and the larger the country, the more resources are needed.

China has made extraordinary efforts to understand and contain COVID-19. China’s public health system became much stronger after SARS. Those of us working in global public health hope that, just as SARS led China to step up the function and investment in China CDC, the current effort will trigger another exponential leap in public health capacity in China.

Compared with the strongest public health systems in the world, China has great strengths, including community mobilization. In other areas, China’s public health system has the potential to increase its contributions to China’s growth and development. This will not only better protect the health of the Chinese people, but also have a ripple effect regionally and throughout the world.