In 1900, average life expectancy in the United States was 47 years. By 1999, it was 77. The medical breakthroughs of the 20th century were remarkable but not primarily responsible for the increase. Advances in public health — such as safer food, cleaner water and lower tobacco use — accounted for 25 of those 30 additional years.
As commissioners of the Chicago Department of Public Health, current and former, we have dedicated our careers to furthering that progress and the core principle upon which public health is built: Every person, no matter who they are or where they live, deserves the opportunity to live the healthiest life possible. But that principle — too often ignored or undermined in the 21st century — now faces an imminent threat from Washington with public health funding a potential casualty as federal policymakers negotiate over the nation’s debt limit. A default would likely result in economic catastrophe. But a debt limit agreement that either cuts public health funding or “claws back” funds previously distributed to health departments that they have not yet spent would be calamitous as well. This is a moment to invest in and rebuild, not tear down, our nation’s public health infrastructure.
Together, we have nearly 30 years of combined service to Chicago’s health department. Thanks in large part to our tireless and heroic staff, the department has achieved meaningful results: from helping an additional 275,000 Chicagoans obtain health insurance under the Affordable Care Act to driving HIV rates to their lowest levels in decades. When public health emergencies occurred — COVID-19 and, in 2009, the H1N1 flu — the department responded quickly to save lives.
No two public health departments are exactly alike, and each jurisdiction they serve is unique. But our decades of service have taught us what all public health departments need to maximize their potential: sustainable, long-term funding; flexibility to make decisions that best serve local needs; and ample time to make those investments and evaluate their effectiveness. That formula helps ensure public health departments can improve people’s daily lives while being equipped to handle emergencies, whenever and wherever they strike.
Unfortunately, that formula is rarely followed. Investments in public health are incredibly cost-effective; every $1 in public health spending can save local governments up to $88 in return, according to a 2016 study of public health in California. But in the two decades preceding the COVID-19 pandemic, only 1 to 2 cents of every health care dollar spent in the United States went to public health and prevention — today, it’s about a nickel — and severe public health funding cuts have hit localities hard. Staffing at Chicago’s health department dropped from more than 1,800 employees in 2001 to fewer than 600 at the outset of COVID-19. Even as total health care spending in the United States far surpasses other wealthy nations, America’s health outcomes leave a lot to be desired.
Despite being severely underfunded, the valiant efforts of America’s public health system to vaccinate the nation against COVID-19 saved millions of lives. Yet with more than 1.1 million lives lost during the pandemic, life expectancy in the United States is now lower than it was in 1999.
Every community in this country will be worse off if the debt limit standoff results in yet another hit to public health. The vast majority of Chicago’s public health funding — 80% prior to COVID-19, more than 90% today — comes from the federal government. While the additional funding received during the pandemic was welcome and long overdue, it was only temporary. Moreover, in part because of overly burdensome rules on how and when most of those dollars can be spent, Chicago can be hamstrung when new health challenges emerge. For example, Chicago used new federal dollars to hire hundreds of new health workers to build up COVID-19 vaccine and testing capabilities, but when mpox suddenly emerged last year, neither those essential workers nor dollars could be directed to that response.
Without a long-term plan to sustain these investments, public health departments will continue to atrophy. As COVID-era federal grant funds expire, Chicago’s health department faces a loss of nearly 70% of its 2022 budget by 2025. Such a swift and massive decline would inevitably mean deep cuts or elimination of essential programs and staff, from laboratory capacity that detects new virus variants, to mobile programs that vaccinate homebound residents, to community-based partnerships that improve health and build trust. This leaves us less prepared.
We are proud of Chicago’s efforts to improve health, but inequities still plague this city — from major gaps in life expectancy between white residents and Black and Latino residents to high rates of poverty and gun violence that disproportionately affect certain neighborhoods. Like many places in America, factors such as race, gender, income, neighborhood and disability status determine who has the opportunity to live the healthiest life possible in Chicago and who does not. Public health, for its part, must do more to address the inequities that fuel these disparities, rather than simply document them. But that requires additional resources.
As federal policymakers continue debt ceiling negotiations, our message to them is simple: Don’t use people’s lives as a bargaining chip. If we want to ultimately lower future debt — not to mention save lives, improve health and strengthen the economy — let’s finally treat public health as an ally, not an adversary. Anything less should be nonnegotiable.
Dr. Allison Arwady has been commissioner of the Chicago Department of Public Health since 2020. Dr. Julie Morita is executive vice president of the Robert Wood Johnson Foundation and was commissioner of the Chicago Department of Public Health from 2015 to 2019.
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