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 The history of medicine has innumerable examples of mankind’s
triumphs over disease: smallpox, typhus, cholera, diphtheria, measles, mumps,
polio, whooping cough, rubella, and many nameless maladies have been consigned
to the dustbin of history. Religious orders, charities, and governments all
played a hand in bringing these diseases to an end. The names are legend: the
Red Cross, the March of Dimes, and today, the American hospitals and clinics
doing mission-driven work, often in the most challenging settings, inspired by
religious and philanthropic ideals.
We also cannot forget the architects and builders of water and
sanitation systems who gave us near-universal access to clean water and waste
disposal, arguably the most impactful public health innovations of all. We
recall as well the draining of dangerous malarial swamps, childhood vaccination
campaigns, and pest control that saved in prospect millions of our fellow
citizens from deadly infectious disease.
These and other great, enduring achievements of past ages should live in our
collective memory. We should never forget Drs. Snow, Fleming, Pasteur, Lister,
Salk, and others whose brilliance and insight have saved the lives of hundreds
of millions.
 This history of high medical achievements performed (often by government) still
calls to and inspires many. But in the intervening years, there has been a new
development: America’s “public” health infrastructure is now largely private.
The evidence is in plain sight. Where do most people receive medical care?
Private institutions. Where are the new life-saving medicines and techniques
developed and debuted? Private institutions. When the COVID-19 pandemic hit,
U.S. Department of Health and Human Services staff, both in and outside of the
Public Health Service, worked endless hours combating it. Yet, most of the work
was done by our partners outside the government. Most of the care, most of the
vaccinations, most of the therapies and treatment innovations, most everything
critical to ‘public’ health was created and diffused by the private sector.
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Our public health infrastructure now is the private
health-care sector, whether for-profit or not-for-profit. Operation
Warp Speed, which brought us three different vaccines in record
time, was largely carried out by private sector actors, with
government providing the funding and overall direction. It couldn’t
have been done otherwise. The notion that America could ideate,
develop, manufacture, and distribute its medical care and
innovations through the government is not only unrealistic, but
frankly dangerous. To recognize this is to begin the
next phase of American public health and medicine. It will not be a
reinstatement of the first age of public health. Nor will it involve
building out the public sector to serve as the be-all and end-all of
health care. This harkening to the past is not only a waste of time;
it is a harmful distraction, a mirage, preventing progress built on
real understanding. The future involves leveraging the extraordinary
creativity and problem-solving capacity of the private sector to
advance public health.
Choosing the best path forward in health care is difficult.
Policy-makers and politicians can get stuck in a rut, praising the
existing public health structure, while ignoring its shortcomings,
pretending it is something that it is not. Trying to “fix” what is
wrong by sending endless rivers of funding is a fool’s errand. Even
the eternal fiddling with payment systems has done little to improve
the public health function. These kinds of political grandstanding
are not only cynical, but fail to achieve lasting good.
Policy-makers should instead think through what existing government
agencies could, and should, do in the future. There is a real role
for government in advancing public health. I wouldn’t have spent the
better part of a decade of my life working in it if I didn’t think
this were so. But we need to recognize what government is good at in
health care, and what it is not. Clear-eyed evaluation of our
achievements, and the many remaining challenges, entails first
understanding that the era of heroic government-run public health
has passed. The future entails enabling our private sector to
advance the same goals, and to go forward to even better ones.
Eric D. Hargan ( @EricDHargan ) founded the Hargan Group and was the
deputy secretary of the Department of Health and Human Services
after serving as acting secretary. |
