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:
- 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
- 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
- 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.
- 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,
The death rate for lung cancer has decreased by 57% since 2001,1 thanks to comprehensive tobacco control efforts creating a social and legal context in which tobacco is less desirable, acceptable, and accessible.2
The HIV death rate decreased by 71% between 2001 and 2021 for all groups, and by 73% for Black individuals (the group with the highest rate).
Birth rates among adolescents decreased by 78% between 2000 and 2020 due to improved access to public health prevention strategies, including comprehensive sexual health education, clinical services, and promotion of healthy relationships and communication practices.3
Despite declines in mortality for all groups in California, significant racial and ethnic health disparities continue. For example,
- Overall life expectancy is 10 to 12 years less for Black individuals (12.6 for males, 10.3 for females) compared to Asian individuals with the highest life expectancy.
- The rate for alcohol-related deaths is the fourth leading cause of death for American Indian and Alaska Native individuals and is 14 times higher compared to Asian individuals.
- The pregnancy-associated mortality rate is about 3.5 times higher among Black women than among white women.
- The HIV/STD death rate is 11 times higher for Black individuals than for Asian individuals.4
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.
- Heat waves, droughts, wildfires and wildfire smoke, and floods result in illnesses, injuries, and deaths, as well as loss of livelihoods—contributing to unemployment, poverty, and housing instability.
- Direct and indirect effects increase chronic and infectious diseases, mental health challenges, and heat- and smoke-related illnesses.
- The impacts have the greatest toll on the health of those already experiencing health, social, and economic inequities.
- Public health monitors population health impacts and partners with state and local government and private sectors to embed the public health approach in efforts to address these challenges.
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.
- In 2021, COVID-19 was the leading cause of death and years of life lost, with over 43,000 Californians losing their life to COVID-19.4
- Millions more experienced severe illness, hospitalization, disruption to education and work, sometimes loss of jobs or housing.
- COVID-19 highlighted and exacerbated existing health inequities. The COVID-19 death rate was significantly higher for Native Hawaiian and Pacific Islanders (409 per 100,000), Blacks (303 per 100,000), and Latinos (263 per 100,000) compared to the statewide rate (247 per 100K).5 Low-income communities suffered disproportionately. They live in crowded conditions, work in essential frontline jobs, and had more exposure to COVID-19. They had less access to resources, creating gaps in health care, information, housing, and economic security.
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.
- 14-day average case rates have fallen from more than 90 per day in August 2022 to less than 1 case per day.7
- CDPH distributed vaccine and antiviral treatment statewide, supported vaccination events, and provided disease prevention messaging.
- Almost 300,000 vaccine doses have been administered to more than 180,000 people, with 116,000 persons receiving two doses.7
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.
- During the pandemic period, rates of ischemic heart disease increased—countering a long-term trend of decline. Data for 2021 showed that the downward trend has returned, reaching an all-time low (37,903 deaths in 2021 compared with 53,577 in 2001).
- Most cardiovascular conditions can be prevented by addressing behavioral risk factors such as tobacco use, unhealthy diet and obesity, physical inactivity, and harmful alcohol consumption. However, recognizing that deeply rooted social and economic inequities are the drivers of many health behaviors, public health informs policies that improve community conditions so all people can enjoy safe, walkable neighborhoods, access to healthy foods, and affordable housing.
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
- This began with a 63% increase in the pre-pandemic period.
- This increase surged dramatically during the pandemic period, with an additional 79% increase in just two years, and over 10,000 deaths in 2021.4
- In 2019, drug overdose deaths overtook ischemic heart disease as the top cause of years of life lost.
- Between 2019 and 2021, there was also a 38% increase in homicides after many years of decreasing or level rates.4 This was driven by an increase in firearm-related homicides.10
- Exposure to gun violence traumatizes survivors and communities, impacting mental health and social well-being.
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
- In California, serious mental illness and substance use disorders have a significant impact on young adults, with mood disorders and schizophrenia as the first and third leading causes of hospitalization, respectively, for Californians aged 15 to 24.4
- Mental health conditions are the second leading cause of years lived with disability for Californians, and the leading cause for children between the ages of 5 to 14, emphasizing the need to strengthen prevention, early identification, and compassionate care.4
Untreated mental health problems or substance use and addiction can result in injury and premature death.
- In 2021, over 4,000 Californians died by suicide.1
- The overall number of suicide deaths has decreased since 2018 because of decreases in older persons.
- In contrast, suicide and self-harm are among the top five causes of death for ages 15 to 44 and rates have been rising in recent years among young Black and Latino Californians.4,13
- Hospitalizations and emergency department visits for mental health-related conditions are higher among Black individuals than for any other race or ethnic group.4
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.
- Recent public health efforts aim to prevent addiction and overdose through harm reduction strategies, public awareness and education, recovery, and support services, as well as innovative approaches to make naloxone and fentanyl test strips more widely available.
- The California Child and Youth Behavioral Health Initiative (CYBHI)14 is an interdepartmental collaborative effort to transform the behavioral health system to be responsive to the current needs of our children and youth. CDPH is leading an educational campaign to normalize seeking support for mental health challenges, and to de-stigmatize behavioral health in communities.
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!!!
Acknowledgments
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.
References
Footnotes
In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay.↩︎