In this pandemic, we have seen clearly how the health of individuals and communities are connected. We are at a critical junction for the public’s health, with real opportunities for better, more equitable lives. But if we make the wrong choices, we risk further threatening community health now and into the future. We also risk increasing the inequities in our societies that COVID-19 has so vividly illuminated.

The choices we make now, both inside and outside of the health sector, will have reverberations for years to come. Now is the wrong time to defund public health infrastructure.

A History Of Neglect And Interference

One reason the pandemic has been so devastating in the United States is because our public health infrastructure has been gutted for decades. The media widely covered the 2018 disbandment of the White House’s National Security Council Directorate for Global Health Security and Biodefense.

This organization’s entire mission was to prevent the next disease outbreak. Its elimination is only the tip of the iceberg, as over 100 rules and policies to protect health were dismantled or rolled back.

In the U.S., public health’s share of the approximately $3.6 trillion in annual health expenditures is under 3%, a figure that has been declining for nearly two decades.

Most health dollars go to the treatment and management of disease, much of it directed to a vast, complicated and fragmented health care system. This is despite evidence that a robust national public health system could save billions of dollars annually by reducing the burden of preventable illness and keeping people healthy.

Governments Forced To Make Cuts

State and local governments are the main sources of public health dollars. Spending for state public health departments has declined by 16% per capita since 2010 and 18% for local health departments. As their budgets get cut, so do the employees and programs dedicated to preventing disease and promoting health.

Despite many working extraordinary hours throughout this pandemic, typically at low salaries, and with gutted infrastructure from the years of cutting public health dollars and services, public health workers have frequently been maligned, ridiculed and harassed. Many are leaving their jobs because of this, taxing already limited capacity.

In 2000, the Institute of Medicine warned that the infrastructure of America’s public health system was eroding. Over 40,000 state and local public health jobs have been lost since then.

It is no surprise that we were ill-equipped to address the COVID-19 pandemic. If we do not urgently reinvest and rebuild public health, the next pandemic may be worse. The pandemic has inspired tremendous interest in study and practice in public health. We can leverage this for an engaged, diverse and skilled public health workforce nationally and specifically to identify, understand, and meet Hawaii’s unique needs.

Hawaii Has Reason To Be Proud

Compared to the rest of the U.S., Hawaii has fared well through the pandemic in many respects. Our positivity rates, numbers hospitalized and total deaths have been among the best in the United States.

American life expectancy dropped by a full year in the first six months of 2020, representing the largest drop since World War II. Across the U.S., nearly 20% more people died this year compared to last, but in Hawaii, our death rate remained largely the same.

Our comparative success has been explored elsewhere and attributed to our geography, strong early control action, community response and a mutual sense of vulnerability and commitment to each other.

Our public health infrastructure should be lauded and further supported. Hawaii leads the U.S. in many critical measures of the public’s health, including the longest life expectancy in the nation. One key reason for this is our long-term focus on theory-based efforts to prevent chronic disease with systems and policy change along with promoting healthy individual behavior.

While COVID-19 has reignited the world’s interest in infectious diseases, most people still die from chronic conditions such as heart disease, cancer and stroke. These conditions also increase one’s risk of death from COVID-19.

Threats On The Horizon

Despite the biggest global health crisis in over a century, several bills proposed in this legislative session threaten core public health programs that have contributed to Hawaii being one of the healthiest states in the nation.

Tobacco is an excellent example. Smoking is the second-leading cause of early death and disability worldwide. Hawaii has been a leader across the U.S. in tobacco prevention and control policies. One of the foundations of Hawaii’s leadership in tobacco control is dedicated funding for prevention and cessation, but this is now being threatened.

These dedicated funds support programs like the Hawaii Tobacco Quitline and smoking prevention programs for children. We are one of the few states that actually spends our tobacco revenue on tobacco programs. We should continue this practice and support prevention for the good of our communities, especially our youth.

In response to the previous economic crisis, we cut core programs in public health and services for vulnerable communities. Instead of being recognized as a health leader, we were belittled by the Associated Press who noted: “Public schools in Hawaii are closed most Fridays, rats scurry across bananas in an uninspected market and there may not be enough money to run a Congressional election.”

Let us learn from 2009. Cheap activities of prevention, like mask-wearing, mean we are less likely to get sick and to sicken our neighbors, friends and family. Similarly, preventive programs that allow opportunities to exercise, reduce diabetes risk, stop smoking, address mental health and avoid sexually transmitted disease save costs and lives.

It can be hard to see things that don’t happen, but the lack of crisis is when public health prevention and planning are working.

Hawaii is lauded for our excellent COVID outcomes and our high percentage of people with health insurance. As the vaccine rolls out, agencies plan ahead and our Legislature deliberates, let’s not cut budgets and programs that prevent disease and promote wellbeing.