10 Steps for a Healthier America.

We will soon have a new president and a new administration. A time for a reset, and potentially a time to tackle some ambitious goals towards improving population health. What might those goals be? I would frame such a question within a topic I have written frequently about: that the production of population health is about creating the social, economic, political, and cultural conditions that make people healthy, and that working towards creating these conditions should be the highest aspiration of public health. In many ways, the creation of a healthier country would ideally represent a wholesale political and economic shift towards an approach where we invest in decisions that prioritize health maximization. I realize that this is a tall order and that efforts such as the Health In All Policies approach have not gained much traction, even as our health as a country overall progressively lags further behind that of our peer countries. With a federal election looming, I thought I would highlight 10 concrete ideas that are both doable and would, if implemented, go a long way toward improving the health of the American public.

In listing these ideas here, I do not in any way suggest that achieving them will be easy, and I am fully cognizant of the political challenges that would need to be overcome to implement these proposals. I intend this to be, however, a set of possibilities, in no particular order. These ideas are doable, if we choose to prioritize them as a society, and they would indeed improve the health of populations. Our job in public health must therefore be to do the hard work needed to pave the way for ideas such as these to be implemented, towards healthier populations.

I note that this piece is informed both by input and ideas I solicited from the school’s Governing Council, and by work I have been doing with the National Academy of Medicine on the recently released Vital Directions initiative. As always, responsibility for the ideas here remains mine alone.

1. Improvements in Early Education

The associations between education and health have been clear for some time now. Education is an important social-stratifier, and can be conceptualized as a fundamental cause of health or disease. Accordingly, improvements in education have the potential to improve health outcomes over the lifecourse. A 25-year follow-up of the Brookline Early Education Project demonstrated an association with positive health behaviors, health efficacy, and lower depression, relative to those who did not receive the intervention. Similarly, a 25-year follow-up of the Child-Parent Education Program demonstrated links to greater educational attainment, income, socioeconomic status, health insurance coverage, and lower levels of justice system involvement and substance abuse. Finally, among pre-term infants, an early education intervention was associated with higher weight, larger head circumference, and greater height relative to controls. Given the importance of early life on health over the lifecourse, improvement of early and pre-K education nationwide are excellent intervention targets, potentially yielding intergenerational benefits

2. Criminal Justice Reform

The incarceration rate in the United States exceeds that of any other country, and is about five times greater than the median rate worldwide. Incarceration rates in the US have risen precipitously since the mid-1970s, and mandatory minimum sentencing on drug offenses in particular has led to an increase in the prison population and average length of stay. In practice, the criminal justice system is rife with disparities, as demonstrated by 2014 statistics showing that on average black Americans are about five times as likely to be imprisoned as whites. Incarcerated populations tend to have poorer physical and mental health than the general population, and the prison environment only enhances the transmission of infectious disease and exposure to trauma. Sentencing reform should focus on reducing racial disparities and shortening prison terms—in particular mandatory minimum and drug-related sentencing.

3. Firearm Control through Legislation

Every year over the past few years, the US has seen approximately 75,000 gun-related injuries and about 32,000 gun-related deaths from homicide, suicide, or accident. Gun violence in the US has reached epidemic proportions, and while other countries, such as Australia, have responded to their mass shootings with sweeping legislation, legislative efforts at gun control in the US have largely stalled. Even research on guns has been de facto silenced at the CDC and NIH. Nonetheless, extant data suggests that implementation of firearm restrictions will reduce firearm mortality rates. We do know that implementation of firearm-legislation will save lives. Our analysis of 130 studies in 10 countries concluded that the “simultaneous implementation of laws targeting multiple firearm restrictions is associated with reductions in firearm deaths.” Other work suggests that background checks for the purchase of firearms, background checks for the purchase of ammunition, and firearm identification had the strongest associations with reduced firearm mortality. Implementing these commonsense approaches is indeed doable, if we can break the political impasse around the issue.

4. Alcohol Control through Taxation

Alcohol misuse is associated with a range of physical problems such as liver disease, cancer, poisoning, injury, and mental health problems, including depression and suicidality. Indeed, a recent report demonstrated a rise in morbidity and mortality among non-Hispanic whites that was explained largely by increasing rates of poisonings due to drugs and alcohol, suicide, and liver-related diseases. Taxation has long been established as an effective alcohol control strategy that has been underutilized in the US. Based on their meta-analysis, Wagenaar and colleagues estimate that a doubling of alcohol taxes in the US as of 2009 would reduce alcohol-related mortality by 35 percent, traffic deaths by 11 percent, and violence by 2 percent. Control of alcohol-related health problems is intimately linked to the availability of alcohol, and political action on reducing alcohol availability and consumption would go a long way towards improving population health.

5. Earned Income Tax Credits

The Earned Income Tax Credit (EITC) is a cash-transfer benefit for the working poor that ranges from approximately $500 to $6,200, depending upon income and family size. Poverty is unquestionably bad for health, and in addition to the direct social benefits of the EITC, its positive effects towards mitigating these health risks have become clear. For example, EITC has been associated with reductions in maternal smoking during pregnancy, low birthweight, childhood behavior problems, and improvements in term birth, breastfeeding, math and reading achievement scores, and improvements in maternal health. Extending coverage of the EITC would go a long way towards improving the health of families in poverty.

6. Health Impact Assessments

Health Impact Assessments are defined by the WHO as “a combination of procedures, methods, and tools used to evaluate the potential health effects of a policy, programme or project.” Health Impact Assessments combine quantitative and qualitative data towards the goal of providing recommendations to policymakers and stakeholders across economic sectors. For example, metropolitan areas considering the health-related risk/benefit assessment of encouraging cycling through a bicycle sharing program could conduct their own customized HIA, taking as a guide and reference the example of an assessment of Barcelona’s program. Broader adoption of HIA in policy planning and implementation stands to improve population health through pathways not typically considered by public health policymakers.

7. Increased Support for Episodes of Special Need Across the Lifecourse

There are several periods that occur during the lifecourse that merit special support for our population, including childbearing, unemployment, and caregiving for sick family members or spouses. The US is one of few countries in the world, and the only high-income country, that does not guarantee paid parental leave for its citizens, despite the known associations with better health among parents, and lower mortality among children. Unemployment is associated with a host of poor health outcomes, including drinking, and caregiving is also linked to poorer health. There is little doubt that increasing and guaranteeing financial support for our citizenry at these vulnerable times during the lifecourse will improve the health of our society.

8. Violence Prevention

Violence can affect anyone. The first World Report on Violence and Health considers violence in a number of forms, including physical, sexual, psychological, or deprivation-based. Many studies, including the Adverse Childhood Experiences study, have demonstrated that childhood abuse is associated with poor health in later life across a range of outcomes. Intimate partner violence (IPV), defined as “physical, sexual, or psychological harm by a current or former partner or spouse,” is another important dimension of violence and its effect on public health. Based on 2011 data from the Intimate Partner and Sexual Violence Survey, lifetime intimate partner rape was estimated at 8.8 percent among women and 0.5 percent among men, while lifetime experiences of other sexual violence by an intimate partner were estimated at 15.8 percent among women and 9.5 percent among men. The experience of lifetime severe intimate partner physical violence was estimated to be 22.3 percent among women and 14 percent among men. There are multiple efforts that have been shown to break the intergenerational cycle of violence. Most impressive perhaps are the innovative strategies employed by the CDC’s DELTA FOCUS Program, which include the promotion of “healthy, respectful, nonviolent relationships” and address “all-levels of the social ecology,” including the fostering of bystander interventions. Nationwide rollout of these efforts could be transformative.

9. Tobacco Control in Low-Income Populations

While the fight against tobacco remains perhaps the preeminent achievement of public health in the 21st century, and some tobacco researchers are currently looking toward a “tobacco endgame,” some populations have been left behind. In particular, a markedly higher prevalence of smoking was observed in 2014 among those below the poverty line (25.3 percent), those with less than a college education, those on Medicaid (29.0 percent), and the uninsured (27.9 percent) relative to the US population overall (16.8 percent). Strategies to reduce smoking among low-income populations include improved access to smoking cessation materials and an expansion of tobacco taxation. These measures could go a long way towards narrowing the current socioeconomic status tobacco use gap.

10. Opioid Addiction and Overdose

Opioid misuse and overdose has in the last 15 years become a major public health crisis in the US. Between 2000 and 2014, the age-adjusted rate of drug overdose deaths in the US more than doubled. This appears to be in part driven by increased access to prescription opioids and the resulting uptick in sales of heroin, an unintended consequence of attempts to curtail and limit access to prescribed opiates. Many attempts have been made to address this problem, but have mostly fallen short of success. Massachusetts seeks to change that with an innovative new program that was signed into law as of March 21, 2016. The law features the following components: limits on opiate prescriptions, a prescription monitoring database, and multiple strategies to identify those at risk of abuse and refer them to the appropriate services. This is an exemplary effort at stemming the tide of overdoses that could, if implemented nationwide, significantly slow this newest epidemic.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: This Dean’s Note was informed by conversations with the school’s Governing Council. Particular thanks to Greg Cohen, MPH, MSSW for his work on this note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/