The public health system?

Last night I set out to explain to my students the structure and functioning of the public health system in the United States. I even drew a picture on the blackboard. I won't try to reproduce it here but think of a plate of spaghetti and meatballs.

At the top, Congress borrows money from the Chinese which it appropriates to various federal agencies. The majority of agencies having a substantial role in public health, broadly construed, are within Health and Human Services, but by no means all of them. Within HHS we have CDC, of course, which includes the Public Health Service and has a mission which is clearly labeled as "public health." But it has no particular oversight or coordination role with respect to such agencies as the Substance Abuse and Mental Health Services Administration, Office of Minority Health, Health Resources and Services Administration, Centers for Medicare and Medicaid Services (which does more than provide health insurance), or of course NIH and AHRQ, which carry out and fund research. Then there is the EPA, Office of Justice Programs within the Department of Justice, the Dept. of Housing and Urban Development, and oh yeah, the Department for the Defense of the Glorious Fatherland, all with significant or extremely large public health responsibilities and in completely separate cabinet departments. Let's not forget the military services either.

For the most part these agencies carry out only limited public health related activities directly. Most of them (with the exception of NIH) make formula grants to the states, such as the Substance Abuse and Mental Health Services Block Grant and the Juvenile Justice Formula Grant, etc.; and have various discretionary grant programs in which the states compete for funds by writing proposals (and politicking, even if they pretend otherwise.) The states spend some of these funds to implement services directly, but use a substantial percentage of them to purchase services from municipal health departments, community health centers, hospitals, community based organizations, and other vendors. And of course the states -- at least the more affluent and blue-tinged ones -- also use substantial amounts of state tax dollars for public health-related activities, including purchased services.

Federal agencies -- including CDC, SAMHSA, and OMH -- also award funds directly to private organizations, largely the same kinds of organizations that receive state funds, and to municipalities and Indian tribes. Municipal health departments, at least in big cities, pass through some of their state and federal funds to private sector agencies, as well as carrying out programs directly.

Non-profit organizations also receive a small but sometimes impactful amount of funding from national foundations -- notably Robert Wood Johnson, Kellogg, and the Commonwealth Fund -- and from local foundations; from corporations, often with ulterior motives such as drug companies paying for screening programs and health education that they hope will help them sell drugs; from United Ways and similar federated campaigns; and from individual donors.

As the money moves through this tangle of pipelines and pumping stations, people at every level make decisions about how it is to be targeted and applied, usually under constraints from above of varying degrees of strictness.

There are major virtues to this decentralization and complexity. It puts a lot of the funding in the hands of agency that are based in the communities they serve, and really know the communities and the people. In fact, this funding is essential to creating infrastructure and leadership, including in communities with limited resources such as immigrant enclaves and other poor urban neighborhoods and rural areas. It is undoubtedly much more effective than if federal and state bureaucracies tried to operate programs themselves.

On the other hand, it is clear that we are not well positioned for a crisis. For example, if there is ever a need to communicate effectively with the Latin American immigrant community in an emergency, and to coordinate outreach and response of some kind, my own agency would be an excellent choice to do it, but no-one at the city, state or federal level has ever consulted with us about this, included us in emergency preparedness planning, provided us with training, or given us resources. This is highly noteworthy because in our ongoing work, our state, federal and national foundation funders have stayed very close to us, through regular grantee meetings, training, involvement in planning and review committees, and access to funding for capacity building and consulting. We know what's going on at every level, what the policies and plans are of the various state and federal agencies, and what is expected of us. And in turn, they listen to us and depend on us to tell them about the needs of our own communities.

As recent events have made clear, there has been no comparable effort to knit together the various agencies and actors that will have to be mobilized in emergencies. We don't have a clue what the local, state and federal health agencies plan to do in the case of a serious epidemic or other catastrophe, nor do they seem to have thought about what we might do to help. That seems unfortunate. We now know that coordination and collaborative planning at higher levels have been comparably deficient.