COVID-19, monkeypox, and infant formula shortages are just a few of the public health challenges the federal government has faced in recent months and years. Despite the federal response to these challenges, criticism of agencies like the Centers for Disease Control and Prevention and the Food and Drug Administration came from both sides of the aisle during both the Trump and Biden tenures.
Several recommendations have recently been proposed to optimize the role of federal agencies; However, many of these can have unintended consequences. Critical to all reforms is prioritizing improving leadership and coordination throughout the federal bureaucracy without eliminating critical duties and roles.
First, reports of an internal review at the CDC prompted by its response to COVID-19 have brought to light a number of concerns, including a rigid financial structure, a lack of authority to collect public health data, and lengthy review processes for scientific ones guidance. The CDC has also been criticized during the pandemic for not communicating its scientific guidance in a way that considers real-world implications. Possible solutions to address these issues include requiring Senate endorsement of the CDC director to increase accountability, giving the CDC authority to collect key public health data, and identifying ways to quickly reallocate funds in case of emergancy.
One idea not to be considered, however, is to drop “prevention” from the CDC’s name and abandon its focus on non-communicable diseases, making it solely an agency for fighting infectious diseases. As we know, the vast majority of deaths in America are due to preventable chronic diseases, and 90 percent of the country’s $4.1 trillion in annual health care spending is spent on people with chronic and mental illnesses. Not only is CDC’s mission central to promoting health and preventing disease more broadly, but its work ensures Americans are more resilient to emergencies like COVID-19. A recent study estimates that two-thirds of COVID-19 hospitalizations are due to obesity, high blood pressure, diabetes and heart failure – all preventable chronic diseases.
Second, the FDA is reportedly reorganizing its food safety program following nationwide infant formula shortages and investigations into its inability to ensure product, baby food and water safety. Solutions voiced at a recent US Senate hearing include a new governance structure that unifies food programs, new models for public-private sector collaboration, and additional resources to hire and retain staff.
One idea not to be considered is to take “food” out of the FDA’s mission, which has encompassed food safety oversight for nearly a century, to create a new agency (and thus likely a new silo). Instead, making sure the FDA starts prioritizing not just food safety but healthier foods is a better choice. Regarding the latter, aggressively tackling excess sodium and added sugars when defining “healthy” on food labels should be a top priority for the agency, as poor diet is now the nation’s leading risk factor for mortality, having surpassed smoking Has. In addition to tobacco, which the FDA also regulates, the agency’s primary responsibility is to fulfill its role as the public health agency that regulates these two leading risk factors for disease.
Third, Congress created the position and office of Assistant Secretary of Preparedness and Response (ASPR) in the Department of Health & Human Services (HHS) over 15 years ago to assist in the nation’s response to public health threats. However, HHS secretaries have not always authorized the ASPR to act on their behalf or provided clear direction to HHS agencies. The Biden administration has proposed moving ASPR from a secretary support office to an agency on par with the CDC, FDA and others, but this does not solve the lack of coordination and alternatively risks creating another silo .
A better idea would be for Congress and the HHS secretary to clarify and strengthen the leadership roles and responsibilities of ASPR during a federal pandemic response, a recommendation recently endorsed by the Bipartisan Policy Center’s (BPC) Future of Health Task Force. was presented. Strengthening of the Office’s recruitment and awarding authorities should also be included. BPC’s task force also recommended coupling leadership of ASPR within HHS with the creation of a new White House Assistant National Security Advisor on Pandemic and Biothreat Preparedness to coordinate, guide and serve all federal departments and agencies Accountable for biodefense preparedness and operational efforts.
Finally, a policy goal that should be pursued, particularly given our experience with COVID-19, is to strengthen our country’s public health infrastructure so that it is able to respond to a wide range of challenges. In addition to a renewed leadership role by the federal government, this requires sustained long-term investments in the federal states and local authorities.
At this point, a recommendation by the Commonwealth Funds Commission on a National Public Health System for a post at HHS, such as that of Under Secretary of State for Public Health, should be favorably considered. This position would help oversee and coordinate the development of a national public health system with federal, state, local, tribal and territorial agencies. Given the urgency to ensure programmatic alignment and budgetary transparency, the commission recommended that HHS, within existing statutory powers, could reconfigure and support the position of Assistant Secretary of Health to fill that role now.
As we near the midterm elections and the 118th Congress in 2023, there are likely to be increasing calls for reform and government oversight of the nation’s federal public health structure. It is important that proposals are examined not only for their merits but also for unintended consequences. As the federal government considers a reorganization or reallocation of responsibilities, it should focus on strengthening its leadership to respond to all emerging and long-standing public health challenges so that we can achieve a healthier nation.
Anand Parekh, MD, MPH, is Senior Medical Advisor at the Bipartisan Policy Center and former Assistant Assistant Secretary of Health at the Department of Health and Human Services.