10 Steps for a Healthier America.

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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

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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

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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

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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: /sph/tag/deans-note/