Public Health Under Pressure: Brian Castrucci, DrPh, on Cyclospora, Trust, and the Cost of Underinvestment

The current Cyclospora outbreak raises questions that extend well beyond a single foodborne pathogen. For Brian C. Castrucci, DrPH, president and CEO of the de Beaumont Foundation, it illustrates what can happen when the nation's public health infrastructure is expected to respond quickly after years of inconsistent investment.

In an interview with Infection Control Today^® (ICT^®), Castrucci spoke with Lead Editor Tori Whitacre Martonicz, MA, about foodborne disease surveillance, reductions in public health funding, workforce resilience, misinformation, science communication, and the erosion of trust in public health institutions.

Throughout the conversation, Castrucci returned to a central argument: Public health should be viewed as essential national infrastructure rather than something that receives attention only when a crisis occurs.

The following Q&A has been edited for length and readability while remaining close to the original conversation.

What Does the Cyclospora Outbreak Reveal About Public Health Surveillance?

ICT: What does this outbreak reveal about the strengths and weaknesses of our current foodborne disease surveillance system? Where are the biggest opportunities for improvement?

Brian C. Castrucci, DrPH: When you think about it, the government's role is to protect our nation. Whether that's from foreign actors, domestic actors, or whatever it may be, the government's goal is to keep America safe and keep America moving.

If you ignore public health and foodborne surveillance, then we're at risk. Just because this isn't something that is cooked up by an individual person doesn't mean it's not a threat to America.

Think about when you get a disease like this and have explosive diarrhea. You can't go to work. Your kids can't go to school. You can't take care of your family or do the things you want to do.

Ultimately, most Americans want to get up, go to work, go somewhere fun on the weekends, live a good life, pay their bills, and make sure their kids have a better life than they do. Any time ill health disrupts that, it's an insult to the American family.

We chose not to invest in public health, and there are consequences. We're seeing a foodborne outbreak that maybe could have been prevented or lessened if we had made the right investments.

When Public Health Funding Falls, What Goes First?

ICT: You've spoken about reductions in public health funding and how they affect outbreak response. During an event such as the current Cyclospora outbreak, what capabilities are lost first? How does that affect state and local health departments' ability to protect the public?

BCC: It's about speed. It's about capacity. Fewer people processing tests. Fewer people with boots on the ground.

You can't underinvest in public health and then expect it to have a fast and swift response.

Unfortunately, we have this boom-and-bust funding cycle. When something is happening, we pour all this money into public health. Nothing happens for a while, so we take the money away. But we need to be prepared for things that are happening that we don't even know are happening yet.

We don't only fund police when there's crime. We don't only fund firefighters when there's a fire. We fund them all the time.

We have to decide that we need to be prepared and ready for any threat we may confront, whether that's a foreign actor, bacteria, a virus, or whatever it may be. I view public health like I view the military, and I think we should be investing in it similarly.

How Can Public Health Rebuild Trust?

ICT: Since COVID-19, trust in federal public health agencies has declined. How does reduced public confidence change the way health officials should communicate during an outbreak? How do they rebuild credibility?

BCC: You have to repair it thoughtfully and by showing up.

We, as public health people, leaders, and practitioners, have to stop using jargon. We have to show up. We have to be there.

During COVID, we didn't have the relationships that gave us credibility. What I really wanted to see was a businessperson get up and say, "Look, I don't want to close my business. This is really upsetting, but I know this health official. I've worked with this health official, and I trust this health official. That's why I'm going to do it."

Now we have to rebuild that. We have to go where people are, whether that's TikTok, LinkedIn, or other places, and start laying out science in a way people can understand.

We're not going to rebuild trust quickly. We need to be at the froyo opening, the Rotary Club, the Kiwanis Club. We need to be places where we're willing to have people challenge us, and we're open to a conversation.

We have to be better communicators. We have to be empathetic. We have to listen. We have to respond in plain language. We have to meet people where they are.

"Trust me, I'm a scientist" isn't going to carry the day.

Why Science Communication Has Become an Infection Prevention Issue

ICT: We're seeing people focus on individual words or phrases and use them to undermine broader scientific messages. How do public health professionals get around that and communicate the truth effectively?

BCC: We, as public health professionals and clinicians, are trained in a lot of different things, and we're rarely trained in communication. That has to become an absolute building block of our training in medical schools, schools of public health, schools of social work, everywhere. We have to know how to communicate effectively.

We also place a very high premium on mortality as a negative outcome, and it is a bad outcome. But there are a lot of other bad outcomes along the way before death.

You're out of work for a couple of weeks. Do most Americans have the savings to pay their rent if they don't have paid sick leave? If you're a restaurant worker or childcare worker, you often don't have health insurance, and you often don't have paid sick leave.

Death is a challenging outcome, but so is being made unhoused because you were sick.

Our messaging has to get better.

Disagreement Is Part of Science, but Misinformation Is Different

Castrucci also stressed an important distinction between legitimate scientific disagreement and deliberate disinformation.

BCC: Disagreement is an absolute part of trusted science because disagreement is the engine of scientific discovery.

But when someone is being deceitful, and I define deceitful as spreading disinformation with an economic or power incentive, I can't work with that group.

There are a whole lot of people who are just trying to figure out how to live their best lives, and there are people out there who are misleading those folks and really hurting their lives and existence. That's where we have to draw the line.

Can the Public Health Workforce Sustain Another Crisis?

ICT: Public health professionals have managed back-to-back emergencies over the past several years, including COVID-19, measles, and now Cyclospora. How prepared is the workforce to sustain this pace, and what investments are most urgently needed?

BCC: I think the public health workforce gives everything it possibly can to protect the American public, but you can only run a battery for so long before it starts to run out.

We have to make a decision in this country about the future of public health. What kind of public health network do we need? What kind of readiness do we want?

We have to start talking about public health and how it is central to the safety, security, and economic prosperity of our nation.

Sometimes we think public health is there to help the poor and underserved, and if you're not poor or underserved, you don't really have to think about public health. That's not true.

Public health helps every person in every corner of every county in this country. If you're a business owner, it helps you. If you're going to a restaurant, it helps you. If you're drinking water, breathing clean air, or going to the pool, these are all ways public health helps you all the time.

I think the best definition of public health comes from my daughter. One of her friends asked, "What's the difference between a pediatrician, who's like a real doctor, and your dad?"

She said, "A pediatrician helps one person at a time. My dad helps everybody all the time."

If that were the universal definition of public health, we'd be in a much different place right now.

Disease Does Not Respect State Lines or National Borders

ICT: We often think about serious infectious disease threats as coming from somewhere outside the US. But people travel constantly, and diseases don't recognize borders. How do we communicate that reality?

BCC: This is the challenge of health. You are only as healthy as the state that invests the least in public health because ultimately, that's the baseline.

I can invest a whole lot in public health, and right next door, the state isn't investing. I might live in Maryland, but work in West Virginia. People are traveling now at a much greater rate than ever before.

We're a small world. It doesn't feel that way, but when it comes to disease transmission, it's a small world.

Putting a whole bunch of emphasis on where something came from isn't necessarily the best use of our time and resources. What we have to do is ensure that people can live the healthy lives they want.

If health were only the bugs and bacteria, this would all be a lot easier. It's about the social world in which we live, where our work, our health, and our faith all interact.

Ultimately, I want you making an informed choice, not a choice based on misinformation and innuendo.

The Final Message: Public Health Helps Everybody, All the Time

ICT: Do you have any final thoughts you'd like to leave with our audience?

BCC: We have to make a decision about funding public health.

Has any other foreign nation ever been able to shut down the American economy? COVID did it. What's the lesson?

We went through COVID. We lost a lot of people. There are a lot of empty chairs at empty tables now. What did we learn from it?

I'm always amazed that we chose to reduce our public health footprint coming out of that instead of taking the time to reinvest in it.

The one message I try to tell people all the time is that public health is actually never against you. We are here to help you live the life you want to live.

We have to start saying that more often so people begin to understand that public health is helping everybody all the time.

Watch the Full Interview

This edited Q&A highlights some of the most important themes from ICT's conversation with Castrucci, but the full interview goes considerably deeper into the erosion of trust in science, the difficulty of distinguishing credible information from misinformation, health inequities, the economic consequences of illness, and what the US learned, or failed to learn, from COVID-19.

Watch the complete interview for Castrucci's full discussion and additional examples that could not be included in this edited Q&A.