10 Ideas for Better Health of the Massachusetts Public.

Before I begin today’s note, a quick word about the SPH This Week publishing schedule. Respecting the heart of summer, we will stop SPH This Week for the next four weeks, starting up again on August 23. We will continue to update the community about events and announcements via SPH Today, and research stories and other school news will continue to appear on our website.

We are in the business of promoting the health of populations. I have written frequently of the role of foundational and structural factors, among them policies and laws, as the core conditions that make people healthy. What, then, are some policy efforts that can indeed achieve better population health, delivering high return on investment yield in our lifetimes? I solicited answers to the question from the School’s Governing Council members—with a focus on the health of the population of Massachusetts—and added to the list a few of my own thoughts. Here I summarize 10 such ideas that rise to the top, in no particular order. This is not a “Top 10 List,” but rather “10 ideas among many.” The intent is to highlight ideas that are indeed doable, and that can yield benefits to the health of populations in both the short- and long-term.

1. 1. Create universal free pre-kindergarten starting at age 3. There is strong evidence to show that early intervention and childhood education has lasting impacts on health and economic outcomes. The period from birth to age 5 is critical in terms of cognitive stimulation affecting future development. In turn, early cognitive development is associated with a broad range of long-term health outcomes. High-quality preschool programs advance school readiness and can prepare children for achievement in school, vaulting them to better educational and job performance in the future. Not surprisingly, the potential benefits of early childhood achievement programs may be more pronounced for economically disadvantaged children, narrowing the “readiness gap” and later achievement gaps. A comprehensive RAND report summarized effects of various early education programs, including significant improvements in achievement test scores, positive behaviors, child abuse reduction, and emergency room visits—all high-yield, short-term benefits. Abundant literature suggests long-term benefits. For example, a longitudinal study found that participation in Head Start was associated with increased probability of graduating high school and attending college among white students, and decreased probability of being convicted of a crime among black students. There was even a spillover effect to participants’ younger siblings; The Abecedarian project, a randomized controlled trial of early childhood education for children from low-income families, found that children in the treatment group were more likely to attend a four-year college and have skilled employment; the Perry Preschool Study found that a high-quality preschool program was significantly associated with high school graduation, higher earnings, fewer arrests, and less time in prison. Outcomes of early education may even span generations to affect the social mobility of children and grandchildren of participants. Such programs can have substantial spillover economic effects, including lower costs for special education, increased labor force participation and earnings in adulthood, increased tax revenue, lower costs to child welfare system, lower costs for criminal justice system, lower medical costs, and economic growth.

1. 1. Clear criminal records for individuals charged with nonviolent drug offenses. We are accumulating a growing number of young men, disproportionately minority, particularly black men, who are unable to get jobs or enter the housing market, largely because of criminal records originating from nonviolent drug offenses. The consequences of criminal records are pervasive and longlasting. Those with criminal records are much more likely to be unemployed. Having a drug offense can also cause rejection from public housing, increased risk of homelessness, and a subsequent spiral of unemployment, unstable social supports, and marginal housing. Both unemployment and homelessness are associated with poor birth, death, and general health outcomes. Importantly, there is ample evidence to show that the likelihood of arrests for drug offences is asymmetrical across groups. For example, blacks are almost four times as likely as whites to be arrested for marijuana possession, despite no significant difference in marijuana use between blacks and whites. Therefore, criminal records perpetuate a cycle of disadvantage, contributing to deepening racial inequalities in health.

1. 1. Increase alcohol taxation in the state. There is no question that alcohol taxation is linked to less alcohol consumption and that said taxation will, in turn, reduce substantial morbidity and mortality in the state. The health consequence of unhealthy alcohol use are abundantly clear, including cardiovascular disease, injury, liver damage, mortality, violence, and other health outcomes. Just to cite one example, Ziming Xuan from our community health sciences department recently led a study that found a 1 percent increase in alcohol prices was associated with a 1.4 percent decrease in the prevalence of adults who binge drink. Several economic studies have found that increasing alcohol prices can lower drinking and driving, alcohol-related injury and death, and alcohol-related violence and crime. Forward-looking alcohol taxation can both decrease alcohol consumption and channel tax revenue into health promoting opportunities such as those discussed here.

1. 1. Establish broader substance abuse scholarship, prevention, and training opportunities. Statewide centers of excellence for alcohol and other drug use on health campuses can train leaders in the field, contribute to knowledge in this area, and enrich the state’s workforce of health personnel who are equipped to deal with substance use prevention. Evidence of the consequences of substance use is overwhelming. To cite just one set of examples, unintentional overdose is the current leading cause of injury deaths among adults. Each day, about 44 people die as a result of prescription opioid overdose; Governor Charlie Baker has made this one of his key legislative priorities. Overdose deaths have also been increasing over the past few decades; from 1999 to 2008, hospitalization rates for overdoses increased by 55 percent, costing about $737 million in 2008. Alcohol and drug use are also associated with increased crime as well as the negative health effects noted above. There is abundant evidence for the success of drug and alcohol prevention programs and a loud chorus of voices calling for the decriminalization of drug-related offences and a focus on substance use as a public health problem. Most recently, the sherriff of Gloucester made headlines by shifting his focus from arresting heroin users to helping them link with care. These approaches hold tremendous promise, and the state can be a leader in scholarship, prevention, and treatment in the area, tipping the national balance on the issue.

1. 1. Raise the minimum tobacco sales age to 21. Raising the minimum sales age to 21 would prevent teenagers from accessing tobacco at an age when they are highly susceptible to addiction and would prevent future generations of smokers. Several Massachusetts cities have already adopted the policy, setting the stage for statewide adoption, The evidence for the benefit of this approach is incontrovertible. Smoking remains the leading cause of preventable death in the US and world Almost 9 out of 10 smokers begin smoking before age 18, and 99 percent begin by age 26. Progression from occasional to daily smoking also usually occurs by this age. Use of multiple different tobacco products (cigarettes, cigars, smokeless tobacco) is common among youth, and the younger a smoker is when they start using tobacco, the more likely he/she is to become addicted. Starting a cycle of poor health throughout the lifecourse, teenage smokers report significantly more shortness of breath, coughing spells, and wheezing than teens who don’t smoke. They are also more likely to report their health as “poor.” If smoking continues at the current rate among youth, 5.6 million of US kids younger than 18 are expected to die prematurely from a smoking-related illness. A recent Institute of Medicine report well showed the public health implications of raising the minimum age of legal access to tobacco products. Several Massachusetts municipalities have already raised the minimum age of access to cigarettes, and some of our faculty have been involved in these efforts through their service on local boards of health, including professors Anne Fidler (Milton), Wendy Heiger-Bernays (Lexington), and Michael McClean (Mansfield). Clearly, however, a statewide change in the minimum tobacco sales age can substantially reduce availability of cigarettes throughout the state, changing the landscape of use for this and future generations.

1. 1. Ban tanning beds. There is scant argument for the continued use of tanning beds. The incidence of melanoma in the US has been increasing for the past 30 years; it is the second most common cancer in 15- to 29-years-olds. The International Agency for Research on Cancer (IARC; part of the World Health Organization) recently placed UV-emitting devices into the “carcinogenic to humans” risk category. IARC also recommended banning commercial indoor tanning for those younger than 18 years of age, because risk for melanoma is higher with exposure at a young age. In 2014, the FDA reclassified UV tanning devices from class I (low to moderate risk) to class II (moderate to high risk) devices. Aside from melanoma, devices that emit UV radiation are also associated with squamous cell carcinoma, eye damage, immune suppression, premature aging, and DNA damage. An outright ban of tanning beds can save a substantial number of lives. Even more limited efforts, including banning tanning beds close to college campuses or enacting age-cutoffs for use, would be a start to curbing an unnecessary health risk.

1. 1. Lead the nation in vaccination rates. Vaccination is one of the sentinel triumphs of public health. A historical analysis in JAMA found a 92 percent decline in cases and 99 percent decline in deaths due to diphtheria, mumps, pertussis, and tetanus because of vaccination in the US. More recently, hepatitis A, acute hepatitis B, Hib, and varicella have cases and deaths declined over 80 percent. An economic analysis estimated that the routine US child immunization schedule saved $9.9 billion in direct cost and $43.3 billion in societal costs for a birth cohort in 2001. Vaccination is considered a target area of the CDC’s Strategy for the 21st Century of Preventing Emerging Infectious Diseases. However, vaccination rates nationally have plateaued, or in some case have dropped over the past decade, with alarming consequences. An outbreak of measles in late 2014 in California was an example of the dangers of refusing vaccination; there were more cases in 2014 than the total number of cases in 9 of the last 14 years, attributed heavily to growing fear of adverse effects of vaccinating children, which have been proven. This represents a “low-hanging fruit” opportunity for Massachusetts to lead nationally by example, by setting the highest vaccine participation standards and by minimizing vaccine refusal rates. Legislation like that recently passed in California, limiting reasons for vaccination exemptions, pave the way. A comprehensive statewide effort, combining legislative efforts and concerted resources invested in maximizing state-level vaccination rates, can provide best-practice opportunities to reverse national trends and boost hard-won decreases in preventable infectious diseases.

1. 1. Mandate health impact assessment for public policies surrounding transportation and housing. Cities shape the air we breathe, the water we drink, and the food we eat. Policies around transportation and housing affect mobility and shelter, but also the health of the state’s urban populations. Creating an evidence base around the health impacts of proposed policies can guide the state towards wiser structural investments that maximize the health of our populations. Health impact assessments can inform recommendations to promote positive health outcomes and minimize negative ones. There are several successful health impact assessment (HIA) examples for the housing sector and transportation. Importantly, health impact assessments have been shown to embed public health considerations into development strategies, in no way minimizing the import of the latter but contributing to the embedding of health as a priority for municipal administrations.

1. 1. Change the restrictions on definitions of homelessness. Although overall homelessness has decreased recently in the US, the rate in Massachusetts has increased faster than any other state. Homelessness in and of itself is an adverse condition that traps many in a cycle of poverty. It is also associated with increased risk of a range of health problems, including drug use, poor nutrition, asthma, HIV transmission, and mental health problems, especially among youth. Many factors contribute to homelessness, many of them multifactorial and complex. However, at a simple level, restrictive definitions of homelessness reduce the number of individuals eligible for affordable housing and increase the number of people who are homeless. Restrictive definitions of homelessness that do not count people as homeless if they are living doubled up with relatives or friends or in motels, for example, mean that only 1 in 10 homeless children in the US are eligible for federal housing assistance. Providing housing vouchers for families and individuals would address homelessness itself and several of its consequences.

1. Establish mental health prevention and intervention programs for military members and Massachusetts veterans. Since September 11, 2001, almost 3 million service members have been deployed to Iraq and Afghanistan. A much smaller proportion of soldiers have died in these recent conflicts compared to previous wars, but this change results in many more veterans returning home with mental and physical health problems following combat. (I shall comment on this further in a future Dean’s Note.) As many as half of returning veterans are faced with conditions including depression, suicidality, post-traumatic stress disorder, impairments in functioning, and traumatic brain injury. Although care of veterans typically falls to the Department of Defense and the Veteran’s Affairs, a study of veterans with psychiatric diagnoses found ample evidence that this care falls short, particularly for reserve members. For example, one study showed an average of seven and a half years between an initial mental health treatment assessment and initiation of minimally adequate care, highlighting a major strain on the Veteran’s Affairs treatment system to provide services. Massachusetts has an opportunity to be the standard-bearer nationwide, to introduce programs that tackle veterans’ health as a core responsibility of a system that has benefitted from the veteran’s service, giving back to many who have given substantially of themselves.

I hope everyone has a terrific week, and a great rest of the summer. Until August 23.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
@sandrogalea

Acknowledgement. This Dean’s Note was informed by conversations with the school’s Governing Council, with thanks to Laura Sampson and Catherine Ettman for contributing data to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/