Q&A with Margaret Hamburg: Why the US needs a national public health system =============================================================================== * Eeshika Dadheech ![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/52/7/13/F1.medium.gif) [Figure1](http://www.thenationshealth.org/content/52/7/13/F1) Hamburg > “We have to start by doing better. Public health agencies at every level, and certainly a national public health system, have to earn trust every day.” > > — Margaret Hamburg The COVID-19 pandemic revealed fractures in the U.S. public health system that hindered response and weakened public trust, according to a June report from the Commonwealth Fund. “Meeting America’s Public Health Challenge” calls for a national public health system that addresses ongoing and future health crises, advances equity and earns trust. Margaret Hamburg, MD, former commissioner of the U.S. Food and Drug Administration and foreign secretary at the National Academy of Medicine, chaired the report’s commission. She spoke to *The Nation’s Health* about the recommendations and the state of U.S. public health. ## Why was the U.S. so unprepared for the COVID-19 pandemic? There were many contributing factors. I actually believe that we were better prepared than our response revealed. And that is the greatest sadness, because many of the capacities that we had weren’t adequately mobilized because of a failure of leadership. But I think that we also suffered in our response, because we underestimated the seriousness of the threat. We didn’t appreciate many aspects about the virus itself and how it would manifest, including critical things like the mode of spread of the asymptomatic infection. We’ve failed to fully recognize the impact of preexisting gaps in our public health system that lead to fragmentation of response, such as the disparities that have existed for a long time in health in our country. This meant that certain populations were more burdened by risk for serious disease because of coexisting medical conditions and gaps in access to care. We clearly saw coordination, communication, testing, surveillance, tracking and tracing gaps in the response. We also saw real challenges related to trust and confidence in public health institutions. ## What are the most important steps to building a national system? Our report tried to outline what we thought were four critical domains of activity and focus. To have a strong, integrated, sustainable national public health system, the (U.S. Department of Health and Human Services) has to embrace a stronger, more focused leadership role. We have advocated for the creation of an undersecretary for health for public health. We also felt that HHS, because it really is where the greatest expertise and programmatic activity around public health lies, should take the lead across the federal government. We also felt that we needed to focus on greater integration, coordination and modernization of our state and local, tribal and territorial public health system. We need to support not just capacity building in terms of public health infrastructure. We need to modernize data systems, laboratories, etc. And we need to ensure opportunities for ongoing training of the public health workforce so they can do their jobs every day as well as also be better prepared to respond to emergencies. ## What is different about this proposal compared to other reports on creating a national public health system? Well, our report built on the work of many other reports and (works by) commissions. But we hope that our report will be coming out at a time with a sort of framework for understanding and action that will enable it to make a real and enduring difference. We wanted to build on the COVID experience, and the lessons learned about strengthening public health and be better prepared for emergencies in the future. But also the recognition that our public health system is failing to fully deliver on its promise every day with respect to serious health issues in communities and across our nation. ![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/52/7/13/F2.medium.gif) [Figure2](http://www.thenationshealth.org/content/52/7/13/F2) A mother brings her daughter to a COVID-19 vaccine clinic in June run by the Los Angeles County Department of Public Health, shortly after federal authorization of vaccines for children under age 5. The nation’s public health system needs a more prominent leadership role, a new report says. Photo by Mayra Beltran Vasquez, courtesy County of Los Angeles ## The report says public health faces a crisis of trust. What created this crisis? Sadly in our nation, we have had an undermining of confidence in government and in certain institutions. We also saw some distrust and gaps in confidence emerging because of failures in performance of the public health system to protect people, and to really adequately communicate to the public and policymakers about what was unfolding. ## How can a national system be developed given today’s political climate? We have to start by doing better. Public health agencies at every level, and certainly a national public health system, have to earn trust every day. And it comes from strong, dedicated leadership, clear commitment to the needs of the public. It comes from being open and transparent in the activities and the engagement with the public. We need to make sure that we are addressing real world needs of people on the ground. We have to be accountable for the work that we’re doing to promote and protect health every day. ![Figure3](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/52/7/13/F3.medium.gif) [Figure3](http://www.thenationshealth.org/content/52/7/13/F3) Workers don protective suits during a disaster drill in Long Beach, California, in May. The training, which involved local health and emergency teams, simulated a chemical contamination. Regular training can improve response to public health emergencies, a June report from the Commonwealth Fund says. Photo by Brittany Murray, courtesy MediaNews Group/Getty Images ## What role can public health workers play? Public health workers are, of course, the unsung heroes of the COVID-19 response. We need to give them the tools they need to do their jobs. And we need to help them put their day-to-day work into a broader strategic framework for public health and sense of mission about the work that they do. We have to make sure that they are applauded, not harassed or denigrated as they do their work. * Copyright The Nation’s Health, American Public Health Association