In June 2021, the Biden administration announced bipartisan support for federal legislation to rebuild our nation’s crumbling infrastructure. The Infrastructure Investment and Jobs Act seeks to revive highway, transit, rail, and public work systems, as well as improve broadband internet access, mitigate the supply chain crisis and combat climate change.

Like most Americans, I am grateful that we are finally addressing our deficits in infrastructure. Nevertheless, this recently signed law forgets one blatantly obvious thing — our deficits in health care infrastructure, as demonstrated vividly by the COVID-19 pandemic.

The past almost two years of the COVID-19 pandemic halted our economy and our daily lives, more importantly resulting in 5.2 million deaths.

Emergency legislation such as the CARES Act and HEROES Act supported already thinly-stretched hospitals but only reflected a fraction of their lost revenue. Despite the best intentions, these band aid-solution approaches resulted in minimal improvement of health care capacity to meet the new demands of the COVID-19 pandemic.

Efforts to “flatten the curve” were necessary simply because the American health care delivery system was already broken and unable to support the growing number of COVID-19 cases. Many U.S. hospitals faced bankruptcy and were shut down, particularly in rural areas where access to care and resources were already limited. Others had to make tough decisions regarding how they would allocate ventilators, space, staff, and other scarce resources. To this day, health care and government leadership still have not conducted the post-mortem analysis to understand fundamentally how and why our health care and public health systems have been so devastatingly incapable of preventing and responding to this threat.

Over the past several years, the number of natural and man-made disasters in the United States and globally has increased, ranging from terrorism and cyber-attacks to shootings and contagious infectious diseases. These disasters have severely impacted health care delivery and population health in the United States.

Even climate change has taken a toll; Hurricanes Sandy, Harvey, and Katrina disabled the operating capacity of entire hospitals and resulted in the loss of lives, both inside and outside of hospitals. Hurricane Maria’s impact in Puerto Rico resulted in critical shortages of saline across the United States. Candidly, such threats become disasters when the new demands placed on our society exceed the supplies, staff, space, and systems able to respond.

These demands often fall entirely upon our health systems, yet U.S hospitals and public health systems lack the infrastructure to rise to the occasion. As a practicing physician who has seen hospital ceilings collapse and flooding during mere thunderstorms, I see how our health care infrastructure is crumbling every day.

High-consequence events demonstrate one truth that biosecurity and emergency management experts have been screaming for decades: Unless we seriously invest in public health and health care delivery, we will be unable to meet the demands of emerging threats, resulting in profound economic and societal loss as well as the loss of lives.

However, the Infrastructure Investment and Jobs Act lacks explicit funding for health system preparedness and infrastructure. Have we learned nothing from the COVID-19 pandemic?

This infrastructure law adopts a broad definition of infrastructure, mindful that the physical plants, spaces, and policies we create in service of the public ultimately impact the well-being of a nation and its people. The law’s noble efforts to address the detrimental impacts of climate change and replace lead pipes in our water systems have notable societal consequences and implications for improving population health.

Still, investing in our health care delivery and public health systems has historically been deficient and continues to elude the current conversation, likely because disaster preparedness and health care resilience are not revenue-generating in the short term.

The last large-scale investment in health care infrastructure was accomplished through the Hill-Burton Act (1946), which attempted to construct and repair hospitals across the United States. It resulted in inequitable, segregated allocation of funding, but proved that infrastructure investment could launch an era of health care transformation.

Nevertheless, the mere fact that government funding for already-outdated hospital systems has not happened in 75 years is alarming. Thoughtful investment in health care delivery with an eye toward disaster preparedness and health equity would improve population health for generations to come.

As politics continue to be divisive, perhaps the lessons we have yet to learn from this pandemic could be common ground. Recognizing public health as an essential element of America’s national security would make public health an attractive business value proposition.

Our nation’s health and our national security are intertwined, and our health care financing should reflect this. A thoughtful approach through infrastructure development could support and sustain a range of physical plant, supply chain, and other improvements in public health and health care systems. It would create large numbers of well-paying health sector jobs, improve health care access and equity, and lead to sustainable economic growth.

Upstream interventions have been desperately required for some time. We should be repairing and replacing our bridges, tunnels, internet, power grid, and the entire American infrastructure – and these efforts will certainly improve population health. However, these interventions are too little, too late, and they represent only an infinitesimal portion of what is required to repair many years of neglect.

The COVID-19 pandemic taught us what happens in times of disaster, and it makes sense to start with rebuilding our society and economy. But now, almost two years into a global pandemic with an embarrassingly uncoordinated, underwhelming response, we urgently need to start with health care. Our safety net has been, and will continue to be, our health systems.

Health care infrastructure demands our immediate attention, not just another emergency act of Congress the next time we are in trouble. With the emergence of ever-new COVID-19 variants, our future depends on reviving our health care infrastructure. Now, at this moment, health care delivery and public health should be our highest priority, greatest return on investment, and most pressing infrastructure allocation.

Charles Sanky is an emergency medicine resident.

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