This piece is part of an ongoing series by Boston University’s Dr. Sandro Galea on the intricacies of health care and public health.
In recent weeks, talk of a Green New Deal has moved to the center of our political debate. The Green New Deal aims to address climate change by tackling the underlying socioeconomic inequities that gave rise to the crisis. It calls for overhauling the country’s transportation system, providing universal healthcare, creating a federal jobs guarantee, investing in infrastructure, and other goals.
This ambition echoes the scope of the original New Deal, another wide-ranging political program that was born out of crisis. In the 1930s, President Roosevelt and his allies used the shock of the Great Depression to transform the relationship between government and citizen through a series of reforms addressing the injustices at the heart of the economic crisis.
Today, the US is in the midst of another crisis, one larger than the Great Depression, larger even than climate change. It is a crisis of health. The US spends more on health than any other country in the world, yet our health is consistently mediocre compared to our peer countries.
Within this context, we face the threat of overlapping epidemics—from obesity, to opioids, to gun violence—which kill thousands each year. The scale of the challenge is captured by a single figure: 0.1. That is how much US life expectancy declined between 2016 and 2017, dropping from 78.7 to 78.6 years. The decrease may seem insignificant until we consider that this is the third consecutive year life expectancy dropped in this country, a multiyear decline not seen since the 1918 flu pandemic which killed about 675,000 Americans.
The challenges that provoked the New Deal and the Green New Deal—economic strife and climate change, respectively—are mere subsets of this broader crisis of health. In my last column, I wrote about the link between money and health, the growing health challenge of economic inequality, and how the wealthiest one percent of Americans can now expect to live 10 to 15 years longer than the poorest one percent.
Climate change, for its part, is a key health challenge of our time, undermining health on many fronts—from the hazard of natural disasters, to the amplification of infectious threats, to the mental health toll of living in the age of a rapidly-warming Earth. Both of these issues, economics and climate, for all their scope, are encompassed by the larger issue of health. We should be no less ambitious in addressing health than we have been in addressing its component parts. The answer seems to me to be self-evident: We need a Health New Deal.
What would a Health New Deal look like? While its particulars would, of course, be open to debate, I suggest that its basic structure should be organized around the following three priorities.
1. Plan all public policies with health in mind
Health does not occur in a vacuum. It emerges from the social, economic, and environmental conditions in which we live. These conditions are shaped by public policy. If we wish to be healthy, we must create policies with an eye towards health.
This was the idea behind the American Public Health Association’s 2013 publication, Health in All Policies: A Guide for State and Local Governments. A Health in All Policies approach challenges lawmakers to view all legislation through the lens of health. They can do this through the use of Health Impact Assessments—systems of analysis that determine the health effects of a given policy or program—and by consulting professionals in the fields of medicine and public health. We have already begun to see a Health in All Policies Approach start to take hold at the state level.
In the current legislative session, 29 bills have been introduced in 11 states addressing policy from a health perspective. They include a New York bill to build a task force to find evidence-based solutions that reduce kids’ exposure to adverse childhood experiences, a Hawaii bill that would create a working group to help with updates to the Hawaii Department of Health’s statutory power and duties, so they will be in line with a more comprehensive approach to health, and a West Virginia bill establishing a Minority Health Advisory Team and authorizing a Community Health Equity Initiative demonstration program. A Health New Deal would help carry this movement forward at the national level.
2. Incentivize health promotion in all sectors
Each day, decisionmakers in politics, business, and other sectors make choices that shape the air we breathe, the food we eat, the neighborhoods we live in, the schools we attend, and other factors core to our health. Sometimes these choices make us healthier, sometimes they do not.
The difference is often a matter of incentives. There are many examples of how incentives can produce healthier outcomes, in both the public and private sector. In recent years, for example, the mortgage funder Fannie Mae instituted its Healthy Housing Rewards Initiative, which provides discounts to borrowers willing to incorporate health-promoting features, such as exercise facilities or green spaces, into their property design.
Incentives at the federal level also shape health. For example, tax credits for the use of solar energy, or for the construction of rental housing for economically disadvantaged households, while not necessarily offered with health in mind, nevertheless have a powerful effect on the conditions that make us sick or keep us well. Likewise, government subsidies for the corn, soybeans, and livestock that are processed into cheap, high-fat foods may have been created for economic reasons, but, by incentivizing the production of foods that contribute to the obesity epidemic, they have significant consequences for health. A Health New Deal would look for new ways of incentivizing health in both the public and private sector.
3. Change the national health conversation
Abraham Lincoln once said, “[I]n this country, public sentiment is everything. With it, nothing can fail; against it, nothing can succeed.” Sustaining a politics of health—not a politics of health care, a politics of health—will take a shift in public sentiment around what we talk about when we talk about health.
We cannot limit the conversation to doctors and medicine alone and call it a discussion about health. This would be like limiting the climate change debate to technocratic chatter about carbon emissions, while ignoring the complex social, economic, environmental, and political forces that created this challenge over many years.
A Health New Deal would shine a light on what we should be talking about when we talk about health, and help shift the Overton window towards bold, transformative solutions. We know this is possible because the Green New Deal is already doing it in the realm of climate change, opening the conversation up to a debate about inequality, social and economic justice, infrastructure, workers’ rights, and more. The creation of a Health New Deal could inspire a similar shift in the health conversation, focusing the national debate on the foundations of health.
The original New Deal was more than an economic recovery package. It was an attempt to leverage a unique historical moment into an enduring public good. In meeting crisis with ambition, it changed this country at the structural level. We are living in unique times once again.
The political upheavals of recent years have pulled back the curtain on a range of inequities that have taken root and now threaten our health. Racism, opioids, economic inequality, food insecurity, and, yes, climate change—these are not problems we can afford to nibble around the edges of. We need a Health New Deal to tackle these core issues, change the health conversation, and create policies that truly safeguard health.
Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His latest book, Well: What we need to talk about when we talk about health, will be published in May 2019. Follow him on Twitter: @sandrogalea