This is the third of a three-part series analyzing public health infrastructure in the United States. Part one can be found here and part two can be found here. This finale analyzes the laws underlying why public health was left to the states and how public health preparedness can be structured moving forward.

When Covid-19 began to spread in the United States, the federal government largely left the states to execute Covid-19 control plans individually. Where national mandates and regulations were needed, the federal government failed to deliver. States created their own plans for overcoming Covid-19 and returning to normal life, all of which resulted in inefficiency and case increases. 

This was not the sole option. The federal government has the legislative and constitutional authority to dictate how the US would control Covid-19. They instead allowed the fractured response that occurred. Federal bodies must levy their governing powers to stop Covid-19 and create a national public health system for the future.

The key to a federal Covid-19 response is “state of emergency” legislation. The National Emergencies Act of 1976, the Public Health Service Act of 1944, and the Disaster Relief Act of 1988 allows the President the authority to declare public health national emergencies, in which time they can exercise emergency powers. In fact, President Trump declared a national emergency for Covid-19 back in March using this legislation.

Historically, the power to regulate public health has been held by the states. Dr. Eric McDaniel, professor of government and health policy at the University of Texas, describes state and federal interaction “like education…it is the responsibility of the state to ensure the health of its citizens, much like the states are responsible for providing education. For the most part, the federal government is there in a support role.”

It seems that public health is one of the powers “not delegated to the [federal government]” and “reserved to the States” by the Tenth Amendment. McDaniel notes that the federal government “may issue guidelines and offer resources, but cannot force the states to abide by them.” However, this constitutional authority comes with a loophole in the form of the previously mentioned “state of emergency” laws.

These laws suggest that the President may use the Public Health Service (PHS) to such an extent and manner that in their judgment promotes the public interest. The PHS includes federal bodies like the Food and Drug Administration, the National Institute of Health, the Centers for Disease Control, and others, as well as a uniformed corps of several thousand military personnel. 

The President essentially has the power to do whatever they need to in the face of a pandemic. If the President were so inclined, they could deploy the commissioned corps of the PHS across the country to run testing and vaccine distribution sites alongside public health officials. In a state of emergency, the President has the authority to override state public health authority.

Were a President to use emergency powers effectively at the start of the pandemic, perhaps we would not be the worst-hit country in the world. We must contain future pandemics promptly and effectively. To do that, there are three pillars of public health that need an overhaul: leadership, governance, research, and social solidarity.


The extent and intensity of Covid-19 took US federal leadership by surprise, to say the least. The fractured response to testing and economic downturn leads me to believe that nobody was prepared for the pandemic until it was too late. To address this, our leadership must be readily informed of new emerging diseases and pandemic awareness. 

The United States’ death toll for Covid-19 is over 220,000. The cold months will force millions indoors and that count will certainly continue up. The American death count for World War 2 is around 415,000. It seems possible Covid-19 could reach a similar height. We must elevate public health policy to the importance of war threats. Trillions were spent on the War on Terror, yet a war against a deadly virus does not warrant the same importance?

Every council, i.e. the National Security Council, National Economic Council, etc., should have a health staffer from the CDC. The Department of Homeland Security should be heavily advised so they could help the federal government prevent internal and international transmission of disease. In fact, the CDC should have staffers in every state government, major city government, and every embassy. The CDC must be ready to inform everyone of impending public health threats and assisting the formulation of effective, timely national policies. They are the intelligence agency to fight a war against disease.


The public health policymaking process begins with health agencies like the CDC, FDA, and NIH under the umbrella of the HHS. Though ultimately, public health policies are instituted and enforced by the President. Making sure the President is making informed decisions is imperative to successful health policy. Minimally, the Secretary of Health and Human Services must be added to the National Security Council to inform the president daily on ongoing disease threats and preventative measures.

Though there needs to be an added layer of health governing. I suggest a new council dedicated to disease and pandemic prevention and response. In a similar vein to the National Security Council, the proposed National Disease Council can be organized between HHS agencies and meet regularly with the President to discuss impending public health threats. There is evidence suggesting the National Security Advisor was aware of Covid-19 as early as November 2019. Imagine the differing response to the pandemic if we had addressed it as a national security threat.

This is all contingent on the willingness of the President to move forward with public health legislation. Some Presidents may take a more relaxed approach to pandemic preparedness. This must be mitigated by the nonpartisan quality of the National Disease Council. Appointments must extend past singular presidential terms. The leadership of the National Disease Council must overwhelm the President with information that would force them into action if necessary.


No less important than the political branch of policy development is the research aspect. All the agencies on the National Disease Council must work tirelessly to be on top of an emerging disease. Partnerships between public universities and private enterprises must continue to work on drug and vaccine developments. 

In 2003, President Bush enacted Project Bioshield: a funding program for the rapid development of medical countermeasures to biological, chemical, radiological, and nuclear weapons. The project directed significant funding to the Biomedical Advanced Research and Development Authority to oversee rapid medical device development. The project has been largely successful as eight medical countermeasures against anthrax, smallpox, etc have been developed.

Despite its success, any federal entity has a chance to be politically subordinated. One president may find the program irrelevant or that biological dangers are not a top priority. This cannot be allowed. Bioshield and BARDA funding must be a bipartisan guarantee. The NIH, FDA, FEMA, and BARDA are essential in overcoming a viral pandemic and cannot risk being politically undermined. After 9/11, Bioshield and BARDA were created. During and after this pandemic, these programs must be emboldened.

Social Solidarity

Finally, the lynchpin of defeating a pandemic is social solidarity. Public health education needs to be so much more than brushing teeth and eating healthy. What is a major reason one may quarantine? To ensure the people around them do not get sick. Public health education must emphasize responsibility to your family, neighbor, and society. If everyone approaches a pandemic situation with similar attitudes, implementing policy decisions will be much easier.Dr. Devi Sridhar, professor of global public health at the University of Edinburgh, emphasizes the need for public health policies to address problems, but to “implement them on an enormous scale that does not leave behind the poorest regions of the world.” This should be the call to action for the United States on a domestic scale. We have a duty to reinvent our public health system in order to protect our most vulnerable. The death and suffering Covid-19 caused in the US should have been mitigated, but hopefully, the lessons we have learned will enable a brighter future for American public health.