California State of Public Health

“Presentation to the California Assembly and Senate Budget Subcommittees”

Public health
State Assembly
State Senate
Budget hearing
Health Officer
CDPH Director

California Department of Public Health


March 19, 2023


I presented the California State of Public Health to the California State Assembly on March 6, 2023 (starting at 31:31min), and to the California State Senate on March 16, 2023.

Huge thanks to Julie Nagasako, director of CDPH’s new Office of Policy and Planning, and her amazing data team!!!

Good morning/afternoon, Chair, and members, I am Dr. Tomás Aragón, State Public Health Officer, and Director of the California Department of Public Health. It’s an honor to be here today to present on the State of Public Health in California.

At CDPH, our mission is “to advance the health and well-being of California’s diverse people and communities” with the vision that all Californians enjoy “healthy communities with thriving families and individuals.”

Health is not the absence of disease or injury—it’s a state of complete physical, mental, and social well-being. The Institute of Medicine defined public health as “what we, as a society, collectively do to assure the conditions in which people can be healthy.”

Public health is OUR collective endeavor to protect, promote, and improve the health of our communities.

Unfortunately, the field of public health is often misunderstood and sometimes confused with health care which is the provision of medical services to an enrolled population.1

For comparison, here are the four pillars of the public health approach:

  1. First, ecological-social—or “eco-social”—which is the relationship of people with their family and social networks, and with their neighborhood and environment; in other words, health happens where we live, learn, work, play, and pray. Think of COVID-19 pandemic and its widespread impacts. Think of the health impacts from climate change
  2. Second, life course and inter-generational processes. Think of Adverse Childhood Experiences and toxic stress, and the inter-generational transmission of the social and biological effects of adversity and trauma
  3. Third, equity and health equity. Think of low-income communities and essential workers with higher rates of COVID-19 exposure, illness, hospitalization, and death. Think of the disproportionate impacts of violence and mental illness on communities of color, especially Black/African Americans.
  4. Fourth, prevention focus, especially primary prevention: Think of laws reducing availability of tobacco products and exposure to second-hand smoke. Think of Smarter Street designs, vehicle standards, seatbelts and child safety seats, and robust safe mobility options to reduce road fatalities.

Well, what have we accomplished collectively? Over the last 20 years, public health has contributed to significant improvements in health and well-being for all groups in California. For example,

Despite declines in mortality for all groups in California, significant racial and ethnic health disparities continue. For example,

Public health works to reduce these disparities by informing policies that address the underlying social, environmental, and behavioral drivers of health, and by regulating selected sectors with high impacts on health; for example, we licensed, certify, and inspect over 10,000 health facilities across the state, including over 1200 skilled nursing facilities and over 400 hospitals.

Equity is a foundational guiding principle in public health. Based on need, every Californian should have the resources and opportunities to be healthy and thrive. This requires prioritizing investments in communities with continuing health inequities.

Today, California faces some of the toughest public health challenges in decades. These challenges include COVID-19, chronic diseases like cardiovascular disease and Alzheimer’s, mental illness and substance use disorder, firearm-related death and injury, and health impacts from climate change and extreme weather. CDPH is building capacity to tackle these public health priorities.

Climate change is a major force impacting the public’s health, affecting all aspects of our health and well-being—affecting access to clean air, food, water, shelter, and physical safety.

Life expectancy steadily increased for 20 years prior to 2020, but due to impacts of the COVID-19 pandemic, we experienced a sharp drop in life expectancy.

Through OUR collective actions we provided testing, vaccination, treatment, and public health guidance. This led to significant reductions in cases, hospitalizations, and deaths between 2020 and 2021. In 2022, COVID-19 dropped to the third leading cause of death.4 Now in 2023 we have reached the lowest levels since the pre-pandemic period—enabling activities of daily life to resume more safely.

COVID-19 will remain with us for the foreseeable future, including the uncertain burden of “long COVID.” Using lessons learned from the pandemic, the California SMARTER plan enables us to manage COVID-19 today and prepare for future surges and variants, as well as respond to emerging infectious diseases.6

Last year, CDPH leveraged the COVID response infrastructure and the SMARTER Plan to respond to the mpox outbreak. We were able to activate systems for surveillance, vaccination, and treatment to highly impacted communities.

Again, at the end of 2022, we leveraged the COVID response infrastructure to address the simultaneous surge of COVID-19, influenza, and RSV. We tracked disease levels and their real-time and projected impacts on the healthcare system. CDPH provided data to local partners and policymakers to guide the response to this “tripledemic.”

The Governor’s 2023 Budget Proposal continues investments to support the state’s efforts to protect against COVID-19 and other public health threats.

California’s population is growing older. By 2030, 1 in 4 Californians will be over 60 years old.8

Ischemic heart disease and Alzheimer’s disease continue to be the top leading causes of death for Californians.4

Cardiovascular diseases contributed to the most deaths in 2021. This condition group includes ischemic heart disease, stroke, and hypertensive heart disease, all of which are in the top five leading causes of death.

Deaths from Alzheimer’s disease have more than doubled since 2000, and about 1 in 10 adults in California experience subjective cognitive decline or memory loss.9 CDPH collaborates with stakeholders to support the Master Plan for Aging8 to prevent and prepare for the growing number of Alzheimer’s cases and forge a path forward for families. Several conditions other than COVID-19 show substantial increases in death rates over the past two years. These include deaths related to alcohol, road injury, and drug overdose. By far, drug overdose has caused the largest increase, with deaths increasing by over 200% between 2011 and 2021.4

Many public health challenges start early in life among children, youth, and young adults, impacting their life course trajectory of physical, mental, and emotional health and well-being. Children and youth are dealing with unprecedented challenges due to the COVID-19 pandemic. As of September 2022, almost 38,000 of California’s children under 18 had lost a parent or caregiver due to COVID-19.11 This type of loss has long-term health consequences and contributes to Adverse Childhood Experiences, or ACEs. Toxic stress over time from ACEs can alter brain development and affect the body’s response to stress. ACEs are linked to chronic health problems, mental health issues, and substance misuse in adulthood. In California, about 6 in 10 adults report experiencing at least one ACE before the age of 18. [cdphcdss2017-aces-in-ca-report-web]

Public Health works with the Department of Social Services and the Office of the Surgeon General to promote policies that prevent ACEs and build safe, stable, nurturing relationships and environments through programs like home visiting.

In the United States, mental health conditions affect more than half of people over their lifetime and contribute to worse overall health and risk of death by suicide.12

Untreated mental health problems or substance use and addiction can result in injury and premature death.

The Governor’s proposed budget demonstrates steadfast commitment to advancing the health and well-being of all of California’s communities, while prioritizing the most vulnerable, through critical investments in the behavioral health system, social safety net programs, and the public health infrastructure.

The Budget provides support for core public health infrastructure. Through the Future of Public Health Initiative,15 the State invested $300 million to modernize state ($99.6M) and local ($200.4M) public health infrastructure and to transition to a more resilient system. Centered on equity, we are building our capacity and capabilities in long-term strategic planning and policy development; workforce development; data modernization, data science, and decision intelligence; emergency preparedness and response; health care partnerships to improve population health management; community engagement and partnerships; and recruitment and retention of a diverse workforce that reflects the communities we serve. This funding is already at work, with many new staff hired across the state to support this transformation.

CDPH is an agency with over 220 programs and 4000 staff, but PUBLIC HEALTH is what WE do collectively to ensure the conditions in which every Californian can be healthy and thrive.

Thank you for your leadership and support!!!


Special thanks to Ms. Julie Nagasako, Director of the Office of Policy and Planning at the California Department of Public Health. Ms. Nagasako and her team prepared initial drafts and conducted all the analyses.


Office of Policy and Planning. California Community Burden of Disease Engine: A Toolset for Epidemiologic Analysis and Scientific Insight. VP3.0. California Department of Public Health; 2023.
California Tobacco Control Program. 30 Years of Success and Innovation: Celebrating the Past, Present, and Future of Tobacco Control in California. California Department of Public Health; 2020.
Center for Family Health, Maternal, Child, and Adolescent Health Division. Adolescent Births Dashboard. California Department of Public Health; 2022.
Office of Policy and Planning. California State Health Assessment Core Module 2023 Update. California Department of Public Health; 2023.
Center for Infectious Diseases, Division of Communicable Disease Control. COVID-19 Age, Race and Ethnicity Data. California Department of Public Health; 2023.
Office of Governor Gavin Newsom. California SMARTER PLan: The Next Phase of California’s COVID-19 Response. State of California; 2022.
Center for Infectious Diseases, Division of Communicable Disease Control. Mpox Data in California. California Department of Public Health; 2023.
California Department for Aging. Master Plan for Aging. California Health; Human Services Agency; 2021.
Alzheimer’s Disease and Healthy Aging Data Portal. Centers for Disease Control and Prevention
Center for Healthy Communities, Injury and Violence Prevention Branch. Homicide in California: Trends in 2020. California Department of Public Health; 2020.
Global Reference Group for Children Affected by COVID-19. COVID-19-Associated Orphanhood and Caregiver Death in the United States. California Department of Public Health; 2023.
About Mental Health. Centers for Disease Control; Prevention
Center for Healthy Communities, Injury and Violence Prevention Branch. Unpublished Analysis: Suicide Rates Among Youth (Ages 10-24) in California, 2011-2020, Based on Comprehensive Master Death File and DOF p-3 Population Projection File Data. California Department of Public Health; 2022.
Children and Youth Behavioral Health Initiative. California Health and Human Services
Future of Public Health Work Group. Investments and Capabilities Needed for the Future Public Health System. California Department of Public Health; 2021.


  1. In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay.↩︎