In the midst of a public health crisis, money has become a major topic of discussion. Here in the United States we’re talking about how much wealth has been wiped away in the stock market; how much our government would spend on a stimulus package; and how to pay for mortgages, student loans, and $60 hand sanitizer if we find ourselves out of work. But what we’re not talking about is how years of underinvesting in public health programs made us vulnerable to the current crisis.
Politicians often do not place a priority on funding for prevention. Why? Because they can’t brag to their constituents about preventing illnesses that never made people sick. They can’t claim victory over stopping a pandemic that never occurred. I have spent my career advocating for the U.S. Centers for Disease Control & Prevention (CDC), the World Health Organization (WHO), and other public health organizations to conduct important and life-saving work. Getting governments to fund public health programming was never easy and it still isn’t. These organizations rarely get the money they request, which often doesn’t come close to what they really need.
We have looked to philanthropy to fill the gap when governments don’t provide public health organizations with the money they need. As a result, those few precious dollars that public health programs are getting are almost all earmarked to donors’ favorite projects. We have created a situation where experts can’t decide where money should go based on the burden of disease, science, and community demands, nor can they be nimble when they see a threat on the horizon. This approach has created a weak public health system that threatens us all.
The United States Centers for Disease Control and Prevention
A lot of anger is being directed at the CDC lately – an anger with which I’m all too familiar as I write this while quarantined in my apartment, exhibiting COVID-19 symptoms, and like most people in this country, without access to a test. It’s easy to be angry with the CDC. But I have to stop myself from raging and remember this is an agency that is responsible for everything from eliminating childhood lead poisoning to combating the opioid crisis, to protecting Americans and the world from disease outbreaks, such as COVID-19. And they don’t get nearly enough funding.
How much do you think the agency responsible for protecting America from health, safety and security threats, both foreign and in the U.S. receives in funding each year? How much do you think its funding makes up as a percentage of the federal budget? Would you believe me if I told you the CDC’s funding makes up less than 0.2% of the U.S. federal budget?
The CDC received $6.8 billion dollars in fiscal year 2020. This budget covers every area of public health. Only $173 million of that $6.8 billion budget went to Global Disease Detection and Emergency Response.
To put that in perspective, the Department of Defense’s 2020 budget is $738 billion, an increase of $21 billion from 2019 funding. The DOD’s budget increase alone was more than three times the CDC’s total 2020 budget. Or to put it another way, the DOD’s total funding in 2020 is more than 108 times the CDC’s funding. Please remember that the next time you hear a politician say that we don’t have enough funding for public health programs. Keep that in mind when those same politicians tell us it’s a strong military that makes us feel safe, strong, and secure. Do you feel safe, strong, and secure right now? I know I don’t.
The public health sector faces another problem. We have looked to private philanthropy to cover the areas of work that governments should fund. This reality means public health funding is earmarked to the pet projects of billionaire donors. Those billionaire donors often then pay advocates to lobby governments around the world to increase the share of public health funding that goes to their pet projects while ignoring other critical areas of public health, such as health emergencies.
World Health Organization
Let’s dive into the numbers to see what I’m talking about. The WHO operates on a two-year budget cycle. In 2018 and 2019, the organization had a budget of U.S. $4.4 billion, but it raised more than $6.4 billion. That’s impressive and might sound like the WHO is a well-funded organization. But let’s remember its two-year budget is less than CDC’s annual budget and we know the CDC’s budget is minuscule given the scope of work and in comparison to other government agencies. And then let us remember that the WHO’s work isn’t focused on the health of one country but the entire world. We can see the financing situation is even worse when we dive in a little deeper.
During WHO’s last budget cycle, some programs brought in more than they projected while others faced significant shortfalls. Those well-financed programs aren’t able to transfer money to underfunded but critical programs because of the way the funding comes in. For example, WHO requested $554 million for the Emergencies Department, the team overseeing the COVID-19 response – the same team that also managed two Ebola outbreaks during that time period. The Emergencies Department received $470 million – only 85% of what they needed to be fully operational.
On the other hand, WHO requested $902 million for polio eradication efforts and it raised more than $1.2 billion (138% of WHO’s polio budget). That’s great if you’re Bill Gates, who has committed to support polio through his foundation. It’s not great when you realize that 20% of the budget for an organization whose work focuses on public health worldwide is going to a single disease. The WHO cannot use those polio funds on any other part of its work. It also means that 20% of staff and resources are focused on one disease while other areas of work don’t have enough funding to do even their planned level of work.
What these numbers tell us
It’s not hard to imagine what comes next. When this crisis is over months, if not years, from now we’ll go back to pretending threats to public health are not world-changing events.
The challenge for public health organizations and maybe a handful of forward-thinking politicians will be to remind citizens of how they feel today. In the middle of a crisis like this, people are scared and are looking to the government to keep each one of us safe and secure, not private philanthropy. The way governments do that is by investing in public health. We need to call on our policymakers to begin funding public health as if our health, safety, and economy depends on it, because it does.
At the same time, public health organizations need to realize that earmarked funds are a barrier to protecting people from the viruses that might not currently exist and the illnesses that aren’t sexy enough to be a cause celebre. Those organizations need to penalize donors who earmark their funds. Sounds odd, right? But organizations should impose a “tax” on donors who want to shape public health priorities top of charging the standard overhead fee to support its broader work. Some organizations already do it.
For example, if donors give $10 million dollars of earmarked funds, they would pay the standard 10% overhead that supports the cost of running the organization, then pay an additional 30% “tax” to support the entire organization’s budget. This would give the public health organization $3 million to support the activities that are determined to be a priority and $6 million for the earmarked work. This shift ensures billionaires and private philanthropy don’t get to determine the work that organizations are doing while leaving critical work underfunded. Changing the way we finance public health could prevent living through another nightmare like this in the future.
These are the sources I used, if you want to dive in deeper: