Boom-and-bust public health funding is holding cities back

What’s needed is a system where public health has the funding to accomplish both its everyday objectives and pivot to quick and effective emergency responses as needed.

On March 1, the Chicago Department of Public Health was notified that a baby residing in a temporary shelter for migrants in Chicago had tested positive for measles. Given how fast measles can spread through an unvaccinated population living in close quarters, this was “go time” for the city’s health department. 

Within 24 hours, the city launched a mass vaccination campaign in the shelter. Three days later, 882 shelter residents had received a measles vaccine and another 784 had their prior measles vaccination confirmed. By March 11, the measles vaccination coverage in the shelter had jumped from 44 percent to 93 percent. 

The campaign paid off. More than two months after the initial case, only 57 people living or working in the shelter had gotten measles. A recent Chicago Department of Public Health and Centers for Disease Control and Prevention study found that the rapid mass-vaccination response led to a 69-fold reduction in the chance of an outbreak of at least 100 cases, and a median reduction in outbreak duration of six weeks. 

As the commissioner of the Chicago Department of Public Health and the executive director of the Big Cities Health Coalition, representing 35 of the largest local health departments in the country, we believe these results highlight the value of a robust public health infrastructure to support rapid response and emergency readiness. In short, it shows how public health saves lives. 

But while this particular campaign was an unqualified success, it is also a cautionary tale. With chronic disease rates rising and public health emergencies increasing in frequency and duration, we can’t afford to have the federal government sitting on the sidelines, forcing local departments to do more with less. Congress must invest in a public health system worthy of the officials who run it and the American people who depend on it. 

Any discussion of public health funding in the U.S. must start with how little there is. 

Despite generating a considerable return on investment, public health and disease prevention receive less than a nickel of every dollar spent on health in our country. More than 129 million people in the United States have at least one chronic disease — which is responsible for 90 percent of America’s annual health care expenditures — yet CDC’s inflation-adjusted budget for chronic disease prevention and health promotion is lower now than it was a decade ago.   

Compounding the lack of funding is how these limited dollars are distributed. The “boom-and-bust” cycle of public health funding leads to sudden increases when disasters strike and then funds disappearing when threats are perceived to have passed. 

If health departments haven’t obligated or spent funds within arbitrary time limits, Congress can and will just take the money back, as it did with the recission of more than $4 billion in COVID-19 funding in a recently enacted appropriations law. Worse still, rather than provide health departments with flexibility, Congress often earmarks dollars for disease-specific purposes. 

“Boom and bust” funding makes no sense. Take Chicago’s measles response, which has been significant — more than 33,000 measles vaccine doses administered, no documented cases since April 20, and only 64 total cases reported since March. But not only has Chicago been forced to draw upon limited funds and resources, it has also been blocked from doing more. 

Specifically, the Chicago Department of Public Health was denied a request to reallocate $18 million in COVID-19 federal funding toward the measles response. This decision limited the city’s ability to secure isolation and quarantine spaces and exhausted the stock of adult vaccines. When federal restrictions unnecessarily hamstring local and state health departments, no one wins.

What is needed is a system where public health has the funding to accomplish both its everyday objectives and pivot to quick and effective emergency responses as needed. Congress can begin by reauthorizing the Pandemic and All-Hazards Preparedness Act. 

Originally enacted in 2006, this law's funding and programs have been instrumental in helping health departments prepare for and quickly and effectively respond to all types of public health emergencies in the moment and before they occur, while also providing important stability during periods of calm. 

The next iteration of this law should reflect the Big Cities Health Coalition's recommendations to bolster our nation’s public health system: 

• Full funding: CDC’s Public Health Emergency Preparedness Fund helps state and local health departments respond to infectious disease outbreaks, natural disasters and even terrorist attacks. But its funding has declined by 30 percent over the last two decades. This fund should be reauthorized at the full funding amount of $1 billion. Similarly, the CDC’s Hospital Preparedness Program should be restored to $500 million to ensure hospitals are equipped to handle patient spikes during emergencies.
• Flexible approach: Big cities are often the first line of defense when a public health emergency strikes, but the time it typically takes Congress to act on emergency funding requests hamstrings our ability to act. Congress should upgrade the Public Health Emergency Fund — which is designed to supplement existing preparedness funds — to distribute funds immediately upon declaration of public health emergencies.
• Long-term vision: The best time to prepare for emergencies is before they happen. Congress should stand up an adult vaccination program, modeled after the highly effective Vaccines for Children Program, to ensure uninsured and underinsured adults can receive at no cost vaccinations recommended by the Advisory Committee on Immunization Practices. Congress should also provide the CDC with the authority to require reporting of essential data for public health and emergency response.

It is a testament to public health officials’ hard work and dedication that the vast majority of Chicagoans are protected from measles. At the same time, we also know there will be more public health emergencies in our future.

These emergencies may be inevitable, but how we respond to them — before, during and after — is very much within our control. We urge Congress to start that essential work now. 

Dr. Olusimbo (“Simbo”) Ige, M.D., MPH, is commissioner of the Chicago Department of Public Health. Chrissie Juliano is the executive director of the Big Cities Health Coalition.