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Eileen Sullivan-Marx, PhD, RN, FAAN
Public health. We have heard this repeated over and over again by politicians, health experts, and media commentators. Over the past few months, the combined negative impact the coronavirus pandemic and systemic racism has had on the public's health has reached a more acute level of global concern. Health inequity has been repeatedly highlighted by researchers and the body of evidence continues to grow. This time it seems different, or at least it must be different. This time, more people are listening, more people want to understand, and the calls for action grow louder by the day. Yet, many of us fear that the outcry is not reaching enough people. Individuals are not heeding the social distancing guidelines or wearing masks in public. We continue to see acts of violence and racism. Change will require each and every one of us to do our part.
As a healthcare community, we are committed to finding answers that address inequities by drawing on previous research, professional backgrounds, and learning from colleagues and communities who have different experiences. Public health is not merely a phrase used at times like these to describe something nebulous. Public health is deeply rooted in prevention, protection, and community engagement. For nursing specifically, we know that when we add the word “nursing” to public health, the context changes. Public health nursing means solutions.
Public health is integral to our healthcare history. In 1798, President John Adams signed into law the “Act for the Relief of Sick and Disabled Seamen” that paved the way for the establishment of the United States Public Health Service Corps (USPHS) (Commissioned Corps of the US Public Health Service, n.d.). For more than 200 years, the USPHS, the largest public health program in the world, has provided disease control and prevention, mental health services, as well as, led response efforts for disasters (Commissioned Corps of the US Public Health Service, n.d.). Nursing is a significant portion of this leadership and, as many of you know, we have a number of Fellows who are officers in the Commissioned Corps.
Public health nursing is evident in our history throughout wars and pandemics. For example, the care of nurses during wartime demonstrated the critical importance of public health nursing.
“In general, the public health expenditures of the 1920s proved that public health nursing could be a purchasable commodity: the public health nursing programs, which had grown up in the first quarter of the 20th century, had helped to lower the mortality rate, to increase life expectancy and reduce significantly the morbidity rate from tuberculosis, typhoid fever, smallpox, malaria, and most infant diseases” (Kalisch & Kalisch, 1982, p. 170).
Leading up to the 1918 Influenza Pandemic in America (1918-1919), organized nursing was formalizing and finding a space to lead. The nurses at the Henry Street Settlement House were driving attention towards the health of immigrants and pushed for greater sanitation measures (Kenn-Payne, 2000). When the pandemic flu of 1918 began, nursing care was gaining ground but the widespread impact on public health was overwhelming. Lillian Wald, founder of public health nursing in New York City, wrote to a friend that "the wolf is scratching at our door" in explaining that 40,000 nurses were needed for the city's poor (Kenn-Payne, 2000, p. 151). The pandemic showed the variation in how public health nurses were received by the public. Some nurses were overwhelmed with the demand to visit sick families, while in other parts of the country, nurses were shunned for fear they might be contagious (Kenn-Payne, 2000).
Today, as the pandemic has spread across the globe, it is interesting to see how public opinion and understanding seems to mirror history. While nurses are widely lauded as heroes in their communities, we know that there is unfortunately stigma against Asian American nurses and anecdotal reports of healthcare providers being shunned while in public settings for wearing their scrubs. And yet, nursing continues to push forward and lead, drawing on our rich history of public health. A lack of understanding and fear requires education and for that we need more public health nurses who are in the community to educate. Unfortunately, public health, the resource needed in times of crisis, has experienced extensive setbacks.
In recent years, we have seen a continual decline and devastating data on the nation's public health due to the lack of funding and cuts to the public health infrastructure. According to the Trust for America's Health (TFAH), between 2008 and 2017, more than 55,000 positions in local health departments were eliminated. Further, data revealed that the system is underfunded by about $4.5 billion (TFAH, 2019). In considering the larger picture, public health funding accounted for approximately 2.5% of the $3.5 trillion spent on health care during that time. In 2018, there was a slight overall increase (2%) in state budgets, that totaled $11.8 billion (TFAH, 2019).
The Prevention and Public Health Fund (PPHF) was established through Section 4002 under the Affordable Care Act. Funding for this program has gone to the CDC immunization program; block grants in all 50 states, the District of Columbia, eight territories, and two Native American tribes to address various public health needs at the local level; Epidemiology and Laboratory Capacity Program and the Childhood Lead Poisoning Prevention Program and reducing healthcare-associated infections, among others. In fiscal year 2018, the fund allocated more than $586 million of its $800 million budget to states and municipalities (Johnson, 2019).
However, since its creation, the PPHF has often been an example of where the federal government has “robbed Peter to pay Paul.” In 2012, more than $6 billion was cut from the fund over nine years to pay for Medicare physician payments. In 2013, PPHF was cut by $450 million to be invested in the health insurance marketplace. In 2017 and 2018, it was much of the same: over $750 million was taken from the fund to pay for the Children's Health Insurance Program in 2017 and $1.35 billion over 10 years was cut in 2018 through the Bipartisan Budget Act (Johnson, 2019).
The coronavirus pandemic has only furthered the battle cry for increased public health funding as so many in the community have warned over the years. To address the need, Congress has responded through the multiple spending packages signed into law since March. Coronavirus Preparedness and Response Supplemental Appropriations Act [P.L 116-123], the Families First Coronavirus Response Act [P.L 116-127], and Coronavirus Aid, Relief, and Economic Security (CARES) Act [P.L 116-136], have added billions to the public health infrastructure, but it is not enough to cover the drain on the public health infrastructure over the last decade.
Now, as we grapple with systemic racism, we know public health must be a priority. In a recent article published in the Journal of the American Medical Association, the authors stated, “One way that racism adversely affects minorities is through the negative beliefs and stereotypes about race that are embedded in US culture” (Williams & Cooper, 2020, p.3). The authors further outlined, “Health care workers are heroes because they care for patients affected by this pandemic, but they are also human, working under stressful conditions that increase the risk of biased behavior” (Williams & Cooper, 2020, p.3). We have to combat this with education and policy change within our own ranks and in the larger community. As the nation confronts measures to end police brutality and commit to Black Lives Matter, we know, as nurses, that we have influence in the community to speak to better ways to have safe public environments and personal well being through community engagement and ethical practices. We need to use this influence to advocate for communities and for health and safety.
There is a better solution than the current system and it must involve public health. I reflect on words from Lillian Wald that still ring true today. She stated, “Reform can be accomplished only when attitudes are changed.” Moreover, Lillian Wald was a proponent of advancing full rights for Black people and Black nurses. As the first President of the National Organization for Public Health Nursing, she ensured that Black nurses were directly admitted to the organization without having to go through state level organizations, which might have banned them from membership, as was the practice at the American Nurses Association at that time. When faced with greater tuberculosis mortality and morbidity rates among Black communities, Wald hired the first Black nurse, Elizabeth Tyler Barringer, to work with the Black population at the Henry Street Settlement House ( Carnegie, 2000 , pp. 112-113; 153). Additionally, as part of her social justice activism, she hosted a dinner reception the evening before the inaugural meeting of the National Association for the Advancement of Colored People (NAACP) in 1909 at the Henry Street Settlement House ( Wald, 1934 , pp. 8-10). Surely, we can pick up from Wald's inspiring actions and move forward.
The American Academy of Nursing is ready to continue our work to change attitudes by having more conversations, contributing more evidence, and examining how we can change policies in our own institutions as well as at the global level to promote health equity. In May, the Academy recorded a series of short videos from Academy leadership, Living Legends, and Fellows in honor of National Nurses Month and in recognition of 2020 as the International Year of the Nurse and the Midwife. Dr. Alicia Georges, an Academy Living Legend stated in one of these videos, “problems start in the community and the problems must be resolved in the communities.” Further adding to the weight of the statement, Dr. Linda Schwartz, Living Legend, stated, “Through the suffering and joy and frustration of the human experience, nurses, every minute, every hour, every day, practice a profession that eases pain, settles confusion, turns sickness into health, and quietly celebrates the true meaning of human dignity.” It is here that nursing must continue to live, in the center of our communities respecting the true meaning of human dignity. The Academy will work every day to achieve this.
