Introduction

Throughout American history, significant improvements in life expectancy and quality of life have been achieved through strategic investments in public health infrastructure. The establishment of municipal public health authorities in the 19th century enhanced sanitation and reduced mortality from infectious diseases such as typhoid and cholera. Contemporary strategies focusing on healthier environments and improved clinical service access have advanced the prevention and management of chronic diseases like cardiovascular disease and cancer. Public health sectors have played multifaceted roles including disease surveillance, stakeholder coordination, and informing policymakers and the public about best practices.

In the context of Sustainable Development Goals (SDGs), these efforts align with SDG 3 (Good Health and Well-being) by promoting health and well-being for all ages. However, recent declines in life expectancy in the United States, driven by drug overdoses and chronic diseases, alongside persistent health disparities across racial and socioeconomic groups, underscore the urgent need for comprehensive health interventions addressing both medical and social determinants of health.

Despite increasing demands, federal investment in public health has declined, resulting in workforce shortages and outdated infrastructure that limit capacity and emergency responsiveness. The COVID-19 pandemic has exposed and exacerbated these challenges, highlighting systemic inequities in healthcare access and outcomes. This report examines the public health sector’s experience during COVID-19, the influence of legacy systems on response capacity, key contributions and challenges faced, and priority policy considerations to strengthen public health infrastructure in alignment with the SDGs.

The Pre-Pandemic State of Public Health

Mandate and Governance

The mission of public health in the U.S. is to ensure conditions that allow people to be healthy, as defined by the Institute of Medicine (IOM) in 1988. The governance system is complex, involving local, state, territorial, tribal, and federal agencies collaborating to advance public health. Local governance models vary widely, including centralized, decentralized, mixed, and shared structures, affecting decision-making and resource distribution.

This decentralized governance impacts the uniformity of public health services and outcomes, posing challenges to achieving SDG 3 and SDG 10 (Reduced Inequalities). Efforts such as accreditation programs aim to standardize public health mandates and governance but face limitations due to funding and staffing constraints.

Functions and Funding

Public health functions are guided by the “Essential” and “Foundational” public health services frameworks, emphasizing equity and core capabilities such as emergency preparedness, chronic disease prevention, and health promotion. However, funding has historically been inadequate and often categorical, restricting flexibility and emergency responsiveness.

Key challenges include:

• Understaffed and inadequately trained workforce lacking diversity and formal public health education.
• Outdated information technology infrastructure hindering data exchange and surveillance.
• Underfunded preventive programs leading to increased disease prevalence.
• Declining emergency preparedness funding resulting in diminished surge capacity.

These systemic issues undermine progress towards SDG 3 and SDG 9 (Industry, Innovation, and Infrastructure), emphasizing the need for sustainable investment in public health infrastructure.

State and Local Public Health Response to COVID-19

Health Department Functions

1. Emergency Preparedness and Response: Health departments initiated outbreak control, data tracking, and diagnostic support, coordinating with government and private sectors.
2. Assessment and Surveillance: Testing and contact tracing efforts were expanded but faced challenges in accessibility and effectiveness, particularly in marginalized communities.
3. Communications: Departments engaged in public education and misinformation countermeasures, tailoring messages to diverse populations.
4. Policy Development and Support: In the absence of unified federal guidance, local and state agencies implemented and enforced varied public health policies.
5. Community Partnership Development: Collaborations addressed non-medical needs such as isolation support and social services, especially for vulnerable populations.

These functions directly contribute to achieving SDG 3 by managing the pandemic and SDG 17 (Partnerships for the Goals) through cross-sector collaboration.

Health Department Challenges

• Clarifying Roles and Authority: Fragmented federal leadership led to inconsistent responses and confusion over jurisdictional responsibilities.
• Funding Gaps: Chronic underfunding limited foundational capabilities and emergency preparedness, impeding effective pandemic response.
• Addressing Health Inequities: COVID-19 disproportionately affected racial and ethnic minorities, revealing systemic disparities aligned with SDG 10.
• Leadership and Workforce: Public health officials faced politicization, harassment, and workforce shortages, affecting morale and capacity.
• Data Sharing and Technology: Outdated IT systems and data fragmentation hindered timely decision-making and equity-focused interventions.
• Partnerships and Community Engagement: Limited depth of cross-sector collaboration and communication challenges affected public trust and compliance.

Priority Actions and Policy Considerations

To reinforce public health infrastructure and advance the SDGs, the following priority actions are recommended:

1. Transforming Public Health Funding
   • Increase and stabilize funding with flexibility to address emerging needs and health inequities (SDG 3, SDG 10).
   • Implement minimum service packages and monitor spending and outcomes for accountability.
   • Dedicate resources specifically to reduce racial and socioeconomic health disparities.
2. Affirming the Mandate for Public Health
   • Clarify statutory authorities and responsibilities to ensure consistent public health protections (SDG 16 – Peace, Justice, and Strong Institutions).
   • Include foundational capabilities such as risk communication and rapid disease detection in mandates.
   • Support tribal and territorial health departments with adequate resources and technical assistance.
3. Promoting Structural Alignment Across the Public Health Sector
   • Standardize essential services and competencies while allowing local tailoring (SDG 3, SDG 11 – Sustainable Cities and Communities).
   • Encourage regional collaborations and resource sharing to improve efficiency and impact.
4. Investing in Leadership and Workforce Development
   • Expand and diversify the public health workforce with competitive salaries and career advancement opportunities (SDG 4 – Quality Education, SDG 5 – Gender Equality).
   • Develop interdisciplinary leadership models such as the Chief Health Strategist to foster cross-sector collaboration.
   • Enhance training in data science, cultural competence, and communication.
5. Modernizing Data and IT Capabilities
   • Invest in interoperable, real-time data systems to support surveillance and decision-making (SDG 9).
   • Standardize demographic data collection to identify and address health inequities.
   • Leverage public-private partnerships to enhance technological capacity.
6. Supporting Partnerships and Community Engagement
   • Strengthen cross-sector collaborations with community organizations, healthcare systems, and private sector partners (SDG 17).
   • Develop tailored communication strategies to build trust and combat misinformation.
   • Establish sustainable frameworks for community engagement beyond crisis periods.

Conclusion

The COVID-19 pandemic has underscored the critical importance of robust public health systems and the severe consequences of underinvestment and systemic inequities. Public health departments have been central to the pandemic response despite longstanding challenges. Moving forward, addressing structural inadequacies in funding, governance, workforce, technology, and partnerships is essential to protect and promote the health of all communities. These efforts are integral to achieving the Sustainable Development Goals, particularly SDG 3 (Good Health and Well-being), SDG 10 (Reduced Inequalities), and SDG 17 (Partnerships for the Goals), ensuring a resilient and equitable public health infrastructure for the 21st century.

1. Sustainable Development Goals (SDGs) Addressed or Connected to the Issues Highlighted in the Article

• SDG 3: Good Health and Well-being – The article focuses extensively on public health infrastructure, disease prevention, health equity, and pandemic response, all central to ensuring healthy lives and promoting well-being for all ages.
• SDG 10: Reduced Inequalities – The article discusses racial and socioeconomic disparities in health outcomes, emphasizing the need to address systemic health inequities and social determinants of health.
• SDG 6: Clean Water and Sanitation – Historical improvements in sanitation and ongoing challenges related to basic public health resources such as running water are mentioned.
• SDG 9: Industry, Innovation, and Infrastructure – The need to modernize data and IT capabilities in public health departments highlights the importance of resilient infrastructure and innovation.
• SDG 17: Partnerships for the Goals – The article emphasizes cross-sector partnerships and community engagement as vital for effective public health responses.

2. Specific Targets Under Those SDGs Identified Based on the Article’s Content

• SDG 3: Good Health and Well-being
  • Target 3.3: End epidemics of communicable diseases and combat other communicable diseases.
  • Target 3.4: Reduce premature mortality from non-communicable diseases through prevention and treatment.
  • Target 3.d: Strengthen the capacity of all countries for early warning, risk reduction, and management of national and global health risks.
• SDG 10: Reduced Inequalities
  • Target 10.2: Empower and promote the social, economic and political inclusion of all, irrespective of race, ethnicity, or socioeconomic status.
• SDG 6: Clean Water and Sanitation
  • Target 6.1: Achieve universal and equitable access to safe and affordable drinking water for all.
• SDG 9: Industry, Innovation, and Infrastructure
  • Target 9.c: Increase access to information and communications technology and strive to provide universal and affordable access to the Internet.
• SDG 17: Partnerships for the Goals
  • Target 17.17: Encourage and promote effective public, public-private and civil society partnerships.

3. Indicators Mentioned or Implied in the Article to Measure Progress Towards the Identified Targets

• Indicators for SDG 3:
  • Incidence and mortality rates of infectious diseases (e.g., COVID-19 cases, hospitalizations, deaths).
  • Life expectancy and mortality rates (referenced in the article as declining life expectancy in the U.S.).
  • Coverage and capacity of testing and contact tracing programs.
  • Public health workforce size and capacity (e.g., number of public health workers, training levels).
  • Emergency preparedness funding levels and response capabilities.
• Indicators for SDG 10:
  • Disaggregated health outcome data by race, ethnicity, and socioeconomic status (e.g., COVID-19 infection and mortality disparities).
  • Access to health services and social determinants of health resources in vulnerable populations.
  • Funding allocated specifically to health equity initiatives and social determinants of health.
• Indicators for SDG 6:
  • Access to basic public health resources such as running water in communities.
• Indicators for SDG 9:
  • Availability and modernization of public health IT infrastructure.
  • Interoperability and timeliness of public health data systems.
  • Number and quality of data dashboards and real-time surveillance systems.
• Indicators for SDG 17:
  • Number and effectiveness of cross-sector partnerships involving public health departments.
  • Community engagement metrics and collaborative initiatives (e.g., Health Equity Task Forces).

4. Table of SDGs, Targets, and Indicators Identified in the Article

Source: nam.edu