Harvey V. Fineberg, MD, PhD1
JAMA. Published online January 24, 2025. doi:10.1001/jama.2025.0485
On the most basic measures of health, the US is falling short. In 1990, life expectancy in the US ranked 35th among 204 countries for males and 19th for females; by 2021, US rankings had fallen to 46th for males and 47th for females.1 State-by-state comparisons reveal startling health disparities within the US: in 2021, age-adjusted mortality in the worst-performing state, Mississippi, at 867.5 per 100 000, was twice that in the best-performing state, Hawaiʻi, at 433.2 per 100 000.1 Within the US, 14 states had declines in life expectancy between 1990 and 2021.1 Overall life expectancy at birth in the US rose in 2022 over that in 2021 by 1.1 years to 76.5, though still below prepandemic levels.2 Despite spending nearly 50% more per capita on health than the next highest-spending countries, or as much as $4.9 trillion in 2023, US health indexes fall below those of dozens of poorer countries.3,4 When it comes to obtaining health for dollars, the American people have been shortchanging themselves. There is no better way than through advancing health to “make America great” in the 21st century.
Challenges
Among the core difficulties in setting priorities for public health are the enormity of the challenge, the variety of compelling needs, and the range in potential strategies from targeting at-risk individuals to altering underlying social conditions. The vast sums lavished on medical care cannot readily be redirected to more promising avenues of disease prevention and health promotion, and funding to promote the public’s health is constantly constrained. For example, where will the money come from to cope with the alarming rise in obesity and overweight in the US, and what combination of policy, education, regulation, marketing, surgery, and medication will have the greatest impact and be cost-effective? It does not help that many public health successes are invisible—when they work, people do not get sick, and who counts the number of myocardial infarctions that did not occur?
Setting public health priorities rationally involves a combination of data and analysis (How big is the problem and what will be the effects of an intervention?) with value judgments (What aspect of the problem do I care about, and how much do I care about it compared with other health and social objectives?). For example, does maternal health matter on its own, should it be advanced mainly in connection with protecting the rights of women, or should it be considered mainly in connection with avoiding the death of an unborn child? Or consider: how important is eliminating disparities in health outcomes compared with improving overall health outcomes even at the risk of widening disparities?
The values any citizen or decision-maker brings to matters of public health are conditioned by their worldviews, experiences, and beliefs, and the polarized nature of contemporary society makes reconciling contending views especially challenging. Differences in values will affect both understanding of the health problem and the attractiveness and acceptability of different strategies to solve the problem. Many differences in value judgments masquerade as arguments about the effectiveness of different approaches to protect the public’s health; we too often decide what is effective because it is what we prefer rather than decide what we prefer because it is effective.
A major shortcoming in many priority-setting exercises is that they focus predominantly on the need and do not sufficiently consider whether the degree of needed change is attainable in a timely way, or ever. Program implementation often runs into many obstacles, anticipated and unanticipated. Public health interventions typically involve a multitude of actors at local, state, and federal government levels, plus industry, local leaders, health care professionals, and the public at large. Even public health successes may fall short of their potential. For example, the warp-speed campaign to develop a safe and effective COVID-19 vaccine in record time saved many lives, but the failure to immunize others due to vaccine hesitancy or other circumstances is estimated to have cost several hundred thousand lives in the US.5
In a dynamic field such as public health, the US faces some currently high causes of disability and death that are on the decline (such as heart disease and cancer overall) and some currently lower threats that are on the rise (such as long COVID, depression, dementias, and metabolic diseases). This presents a difficult choice: is it better to prioritize the still high causes and double down on such interventions as smoking cessation and control of high blood pressure, or should a higher priority be placed on conditions with worsening trends, such as depression and obesity? The tempting answer is both, but the point of priority setting is to make the best choices in the face of limited resources.
Fortuitously, some public health interventions offer the dual advantage of health benefits and net economic savings. One recent review of the cost-effectiveness of 51 public health interventions found 13 that would produce net monetary savings, many in the core areas of nutrition, tobacco cessation, and alcohol use.6 However, commercial interests and contrary individual values may deter the adoption and implementation of such interventions.
Analogous to the question of prioritizing health problems according to their current scale vs according to their trend over time is the question of the degree of emphasis on anticipated future problems—such as the health effects of climate change or the potential impact of artificial intelligence—compared with the current burdens of disease. As the COVID-19 pandemic harshly taught, threats to public health from emerging infection can arise at any time, and bird flu looms. Prioritizing preparation for future health threats that are not currently manifest seems one of the hardest lessons for public leaders to absorb.
A further challenge in priority setting for public health is appreciating the importance of global health investment in protecting US health. Pandemic preparedness is a prominent case in point, but many health challenges, ranging from antimicrobial resistance to food safety, depend on international collaboration. US investment in global health is less a matter of charity than of enlightened self-interest.
Taxonomy
Depending on one’s purpose, there are a variety of ways to parse candidates or targets for public health attention. I find it useful to distinguish 5 classes of candidates for public health intervention. In general, it is more straightforward to compare candidates within a class and more difficult to decide on priorities across the several classes.
Class 1: Conditions According to Burden of Disease
This class allows a ranking of priorities according to the burden of disease on the US public. There is a difference between the burden in terms of mortality (such as heart disease, cancer, and stroke) and the burdens in terms of disability (such as low back pain, mental depression, and drug use disorder).
Class 2: Lifestyle and Behavior
These are the individual choices that can have a profound effect on likelihood of illness, disability, and premature death. Potential targets include diet and exercise, use of tobacco, alcohol consumption, and drug use. These targets are identifiable as individual risk factors, but they are socially conditioned and can typically most effectively be remedied by a range of policy, regulation, social intervention, medication, and education.
Class 3: Collective Actions That Directly Impact Disease Prevention and Health Promotion
Examples include immunization, clean air and safe drinking water regulations, firearm violence reduction, and automobile safety requirements. Many of these interventions depend on a combination of federal and state authorities, action at the local level, and public-private partnerships.
Class 4: Underlying Conditions That Create, Sustain, or Exacerbate Risks to Health
These cover a wide swath, from public understanding of science and trust in expertise through social media misinformation and disinformation, social isolation and loneliness, environmental hazards, poverty, and racism.
Class 5: Institutional Capacities to Prevent Disease and to Protect and Promote Health
This begins with attention to improving access, reducing cost, and elevating the quality of health care, including preventive services, for all US residents. It extends to funding, strengthening, and certifying local health departments. It includes improving the functions of core health agencies, such as the Centers for Disease Control and Prevention and the US Food and Drug Administration; establishing superior pandemic preparedness; and strengthening channels for international collaboration in health. Importantly, rebuilding the public health workforce, incorporating the tools of contemporary data science into routine public health, and pursuing a strategic health research agenda all warrant attention.
Criteria
I suggest 4 criteria to help choose among the possible targets for public health priority.
Importance
The target should make a big contribution, directly or indirectly, to the health of Americans. This favors problems or conditions that are severe and affect many people or that markedly impede health or prevention of disease. This criterion includes consideration of near-term and long-term effects and of specific populations that may be disproportionately affected.
Feasibility and Scalability
The steps needed to act on the priority should be identifiable with a clear, although possibly multilayered, path leading to improvement. A priority without designated leadership, adequate funding, and an implementation strategy is an empty gesture. There should be sufficient confidence in the desired outcome to overcome uncertainty in recognized and unrecognized adverse consequences. The program should scale to the level needed for population impact.
Value
The returns for health should be worth the costs. Immunization delivers an estimated $26 to $51 in value for every dollar expended. 7 Because of that extraordinary cost-effectiveness, public health is sometimes held to the standard that it should produce net financial savings, and with some interventions, it does. Beyond those health interventions that literally return more economic value than they cost, priority should be given to those that produce greater health benefits per dollar expended.
Acceptability
The program goals and implementation strategies should be politically viable, compatible with public attitudes and values, and acceptable to the involved and affected communities. Co-creation of programs and interventions with the interested and affected parties is one way to help ensure local acceptability of public health interventions.
Discussion
Public health sometimes finds a silver bullet to demolish a problem, but most often, health advances require comprehensive and sustained strategies in research, policy, regulation, education, and direct intervention over time. This has demonstrably been the case with decades of progress against heart disease and cancer.
Public health interventions can take a long time to show their effects, and to select priorities wisely, leaders will need to take the long view.
Setting public health priorities are not a responsibility at the federal level alone. Decisions, policies, and practices at state and local levels can dramatically impact health. While ambiguous sovereignty in public health between individual states and the federal government can complicate execution of national programs, separate state authorities and strategies can create a nationwide laboratory for learning what works best in public health, an underappreciated US asset.
In urgent or emergent priority setting, as in an emerging pandemic, definitive choices and decisive action must often be taken in the face of uncertainty and possible error. In public health, “low-likelihood, high-severity” events create the core dilemma: doing too much in the most likely case and doing far too little in the worst case.
Emerging from the COVID-19 pandemic and at the threshold of a new presidential administration, this is a pivotal moment for setting US public health priorities. To the president, to incoming health leaders, and to the public, it must be said: immunization has saved more lives, reduced more distress, and provided greater economic returns than almost any other public health measure. In setting public health priorities, it would be the height of folly to turn our backs on this cornerstone of modern public health.
Corresponding Author: Harvey V. Fineberg, MD, PhD, Gordon and Betty Moore Foundation, 1661 Page Mill Rd, Palo Alto CA 94304 (harvey.fineberg@moore.org).
Published Online: January 24, 2025. doi:10.1001/jama.2025.0485
Conflict of Interest Disclosures: None reported.
References
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5. Global Epidemics. Vaccinations. Accessed January 15, 2025. https://globalepidemics.org/vaccinations/
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