Legislating to Improve the Health of the Public.

I was sitting in an airport in Paris when I heard the horrific news of yet another mass trauma event, this one occurring in Brussels’ airport and metro system. As of this writing, more than 30 people are confirmed killed, with at least 270 injured. It was, once again, a sadly potent reminder of the consequences of hate. In 2015 I wrote a Dean’s Note about the public health consequences of hate that seems apposite once again. Thus, with sadness, we are rerunning that note in SPH This Week this week, as we will periodically do when the events of the day call one back into particular relevance.

On to today’s note.

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For much of the twentieth century, public health practitioners were taught that states were the primary source of law governing health matters. Until the mid-1900s, public health work was concentrated in local health and environmental departments, where controlling contagious diseases and contaminated food and water in the community were the focus of the profession. Today, however, public health is a far more expansive, national and international field—one in which federal legislation and regulatory agencies provide the legal framework and substantial funding for meaningful public health programs. State and local public health programs still perform valuable core functions in providing services, but many of these (including surveillance, evaluation, Ryan White HIV treatment, and family planning services) would not exist in the absence of federal regulation and funding.

The observation that legal frameworks are supportive of, and necessary for, public health achievement is perhaps self-evident, but worth repeating. Figure 1 below shows how the ten great public health achievements, as articulated by the CDC, are all linked to respective supportive laws at the local, state and federal levels. Several authors have long written about the legal frameworks needed to deal with public health challenges such as the built environment and obesity. It goes almost without saying that health law scholars in our own school have contributed a substantial body of scholarship that informs our understanding of the intersection between laws and the health of populations.

At the same time, of course, we have, as previously discussed in many a Dean’s Note, substantially poorer achievement in health indicators as a country than many of our peer nations. All of which suggests, perhaps, that while we do indeed have legislation to promote particular aspects of health, we have far less legislation that aspires to promote population health through all our other regulatory and legislative efforts. Namely, while we have a mature set of laws that govern HHS, CDC and other health agencies, we are far from having health as a goal for the broad range of federal, state, and local laws that indeed shape the conditions that make people healthy.

基于“增大化现实”技术

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The Health in All Policies approach, first proposed in Europe nearly ten years ago, aspires to make health central to policy-making in all sectors of the economy. The approach recognizes that the production of health must arise from the engagement of multiple sectors, in order to create conditions for healthy populations. Other examples of Health in All Policies approaches include the Adelaide Statement in South Australia and ActNow BC in Canada. The Health in All Policies concept is also embedded in the Affordable Care Act, through the establishment of the National Prevention Council, under the direction of the Surgeon General, which has included the articulation of a National Prevention Strategy that lays out a framework for cross-sectoral action on health. The limitation of the latter, of course, is that it does not establish legislative ties to these actions, but rather acts to frame and nudge action by engaging multiple partners.

In sum, there is little doubt in my mind that legislative action stands to improve the health of the public. The challenge is that much of our conception of legislative actions for public health has focused on the specific regulation of public health (or health more broadly) taken by relevant agencies. While this is of course necessary, it is but a small piece of a much larger picture, and the need exists for a broader embrace of the social and structural changes required to promote health and prevent disease. In some ways, this is a call back to the roots of public health, as exemplified in the British Public Health Act of 1848, echoed in more recent Health in All Policy Efforts. A recognition of the centrality of legislative efforts to the promotion of health, reflected in our school by work led through our Center for Health Law, Ethics, and Human Rights, is an essential component of our efforts to create healthy populations.

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: Thank you to Laura Sampson for her contributions to this Dean’s Note. I am particularly grateful to Professors George Annas and Wendy Mariner for inspiration, and for their substantive comments on earlier versions of this Dean’s Note.

Previous Dean’s Notes are archived at: /sph/tag/deans-note/