The political decision that health matters

On centering health as a value that informs politics, particularly in divided times.

The newly installed administration, like every new administration, inherits a country facing many challenges. These include challenges in our energy sector, at our border, in the emergence of natural disasters, and in the geopolitical tensions that threaten to destabilize our world. They also include, centrally, challenges in health. The U.S. faces a range of problems that have held our health back relative to peer countries, problems such as substance use, gun violence, chronic disease, mental illness, and deep inequities that have created pockets of persistent poor health among populations. For example, black Americans sicken and die at a much higher rate than white Americans from a host of health challenges, such as diabetes, heart disease, and asthma. Black maternal mortality is also higher, as is the likelihood of this population being injured or killed by gun violence. The scale of these problems echoes the scale of challenges to health we see at the global level, including under-five mortality, the threat of infectious disease, and global inequities in health that concentrate a disproportionate burden of poor health in certain regions.

These challenges raise the question: How do we create health? This question is core to the work of public health, and our efforts to answer it have yielded a great deal of data on how to go about building a healthier world. Fundamentally, we create a healthier world by creating the conditions that generate health. This is reflected in the animating metaphor of The Healthiest Goldfish — that of the goldfish who died for lack of clean water. When it comes to health, our “water” is a metaphor for the conditions in which we live. Building a healthier world takes creating healthy conditions, such as clean air and water, nutritious food, accessible education, livable wages, and an end to the misogyny and racism that deprive many of opportunities for health achievement. Ensuring these conditions are in place can play a decisive role in improving health locally, nationally, and globally.

So, given that health can be much better, and that the creation of health rests on establishing a set of conditions that generate it, health is then a fairly simple matter of making sure we have those conditions in place, right? Because we know what generates health, we should be able to act on this knowledge, for the good of all.

That is where this gets interesting. Because while we know what it takes to generate health, we often choose not to do it. On the Center for Disease Control and Prevention’s (CDC) web page, for example, there is a list of interventions designed to improve health by changing conditions for the healthier. They include policies that support access to clean syringes to reduce the spread of disease among people who inject drugs, universal motorcycle helmet laws, multi-component worksite obesity prevention, raising the price of alcohol products, creating safe routes for students and families to travel to and from school, school-based programs to increase physical activity and prevent violence, and tobacco-control interventions such as tobacco price increases, anti-tobacco media campaigns, and comprehensive smoke-free laws. These are all sensible suggestions, their capacity to shape healthier conditions supported by solid data. Yet our implementation of these suggestions has been patchy at best.

Why? The answer is well-captured in the example of needle exchanges, a measure designed to support access to clean syringes. Decades of data have shown that these services do indeed help prevent the spread of disease. Yet they remain controversial and far from universally adopted. The politics of the issue has, in many cases, displaced the data as the deciding factor in whether these programs are implemented in communities. It is, largely, the politics of fear — fear of crime, fear of disorder, fear of discarded needles injuring children, fear of encouraging behavior many see as unsavory and justly stigmatized. These fears, like many fears, are not based solely on the rational. They are not the product of data, of reasoned analysis. They are no less potent for that. They are that ineffable X factor of an issue, the politics of it, that can be hard to quantify but that is often, in the end, the factor that wins out over other considerations in deciding whether a given policy is adopted.

Ultimately, the choices we make about health at the collective level are political choices. Politics is about the allocation of resources and energy within a society, an allocation that is central to whether we can live healthy lives. This means that, while it may seem harsh to say it, when we see our health lag behind the health of peer countries, we are seeing the results of a political choice we are making — and that we could, if we wanted to, unmake.

Now, sometimes, what may appear to be a rejection of health is actually a reasonable engagement with the tradeoffs involved in a particular policy under consideration. I have written previously about this in the context of the conversation about lockdown policies during the COVID-19 pandemic. During the pandemic, there were conflicting opinions within public health about how to approach lockdowns. These opinions reflected the complexity of the moment as much as they reflected philosophical differences within the field. In 2020, we faced a novel virus, in a context of evolving data and a bright media spotlight shining directly at public health. Under these circumstances, some thought the moment called for an effort to drive COVID cases down to zero chiefly by embracing open-ended lockdown policies, which prioritized safety from the disease over other considerations. Others saw lockdowns as a more temporary measure, a blunt but necessary response to our early, less-informed engagement with the virus, which came with its own costs in educational disruptions, isolation, and inequalities between those who were able to more easily adopt a fully remote life and those who were not. Choosing to curtail lockdowns later in the pandemic, in recognition of these tradeoffs, was not a rejection of health, but an effort to balance competing factors in the creation of the conditions that support it.

But, more often than not, I think, we turn aside policies that would support health not after a thoughtful consideration of tradeoffs but because of a shortsightedness in our engagement with health, a spirit of neglect that too-often characterizes the politics of the issues that determine the health of populations.

For example, there are a range of ingredients that go into the food we eat, some of which are good for us, some of which are bad, and some of which have an ambiguous nutritional value. The reason many companies use these foods often has less to do with taste and health and more to do with using the cheapest possible ingredients to create a product that turns a profit. We could more effectively regulate companies, as many European countries do, to ensure our foods are healthier. We could stop subsidizing the production of cheap, unhealthy ingredients such as high-fructose corn syrup. We could more aggressively take on the entrenched corporate interests that have kept our national diet less healthy than it could be. These are political choices we could make to become healthier. That we have not yet made them, reflects, in part, the difficulty of a real reckoning with the political forces that help keep our food, and our populations, unhealthy. But politics is not an arena for easy struggles and quick victories. It is, as Max Weber said, “a strong and slow boring of hard boards.” Making the choice to be healthy at the political level is not an end but a beginning, the start of what is often a difficult path to enacting policies that support a healthier world. We should be clear-eyed about this. Making the political decision that health matters is committing to the long-term task of making the world healthier. This means bringing together a range of stakeholders, working to build a big-tent movement for health, marshaling energy and resources, and investing in the policies and infrastructure that support health. It entails detail and complexity and very hard work. It starts with the political choice that health matters. Everything else flows from that.

In this moment, there is much disagreement over the policies that affect health, which is, at a deeper level, a disagreement about values. It is a disagreement over the question: Do we value health or not? If one sees the world in purely mercantile terms, where it is OK that some human beings live long, healthy lives while others do not, then perhaps it is possible to give some version of the answer “we do not value health” or “we value health, but … .” If this is one’s perspective, it can lead to any number of political choices, some of which we are seeing now, and which do not support a healthier world. They include a disinvestment in the structures that generate health and a skepticism of institutions that, for all their flaws, have played an important role in keeping our country and world healthy. But if we say we value health, if we believe in creating a healthier world, we have made, definitionally, a political choice. This sets us up for all the challenges and satisfactions of political work, it makes us participants in a narrative, the story of health that is, in large part, a story of political struggle. It also commits us to speaking out when we see people taking actions — in the political space and elsewhere — that suggest health does not matter, to emphasizing that health does matter and that, because it matters, it is on us to do what is necessary to build a healthier world for all.

So, in this time of high political dudgeon, it is our job to make the right political choice, to choose health. Perhaps this choice can help shore up our commitment to local and global impact in this moment — because health is interconnected and creating a healthier world for some means, at the end of the day, creating a healthier world for all, the ultimate lesson of the COVID years. This means pushing forward a politics that guides us in a healthier direction, supporting science and shifting values toward a more robust consensus that health matters and is worth striving for, and, at times, struggling for.

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Also this week

Thank you to all who have joined us at the WashU School of Public Health as we have begun our event series for the semester. We still have a range of talks and seminars planned for the coming months. Learn more and register here, as well as access video of past events.

A modified version of last week’s essay appeared in WBUR’s Cognoscenti.