November 5, 2015
This past month, culminating with Election Day, provided much food for thought for those of us passionate about public health.
The election
First, the election. Locally, voters approved two measures that directly align with public health goals. King County voters approved a tax levy to support the “Best Starts for Kids” initiative. This six-year program will support prevention and early intervention strategies, from prenatal care through teen years and into early adulthood, with half the funds devoted to the first few years of life. Examples of these strategies include home nurse visits for first-time mothers, universal access to developmental screening for very young children, increased access to mental-health screenings for middle school-age youth, and flexible funding for families to prevent homelessness.
In addition, Seattle voters approved the “Move Seattle” proposition, a nine-year transportation program. Like all such programs, it will include funding for road and bridge repairs. But Move Seattle also includes substantial funding for transit, pedestrian, and bicycling infrastructure. Expect more bike lanes, more bus lines, and “safe routes to schools” improvements such as sidewalks, crosswalks, speed bumps, and enforcement cameras near schools. Together, these initiatives will promote healthy child development, better mental health care, more physical activity, cleaner air, and injury control—major wins for public health.
But in a loss for public health, state voters approved an initiative designed to limit taxes. A similar statewide anti-tax initiative, in 2012, required a two-thirds majority in the state legislature to raise taxes; this was found unconstitutional a year later, since the constitution empowers the legislature (by a simple majority) to decide on taxes. This year’s initiative seeks the same legislative super-majority, in a more convoluted fashion: by requiring the legislature to bring a constitutional amendment to popular vote. If the legislature fails to do this, then the state’s sales tax, currently at 6.5%, must be reduced to 5.5%. This would shrink the state budget by an estimated $8 billion over the next six years—at a time when the state is under court order to spend billions more on K-12 education.
Anti-tax sentiment runs strong in our state. But I don’t believe that most voters in Washington are proud that one in four high school students (and one in three low-income students) don’t make it to graduation. I don’t believe that most Washingtonians are pleased that our state’s infrastructure—bridges, roads, schools, drinking water, and more—earns only a C grade in a national assessment by the American Society of Civil Engineers. I don’t believe that most Washingtonians are happy that mental health services are rare across much of the state, and that “psychiatric boarding”—holding mentally ill patients in emergency rooms because no appropriate treatment settings are available—is epidemic.
But Washingtonians, like Americans generally, are reluctant to support collective solutions to these problems—the solutions that government provides. President Reagan famously declared in his first inaugural address that “Government is not the solution to our problem; government is the problem.” Sadly, he struck a chord. Public trust in government has dropped from above 75% in the 1960s to below 25% now. Americans, including Washingtonians, are deeply averse to paying taxes. In fact, we pay less in taxes than the citizens of any other industrial country except Chile and Mexico. Americans may want high-quality public services, but they aren’t willing to pay for them.
This is a challenge for public health. The World Health Organization definition of public health refers to creating “conditions in which people can be healthy” and notes our “focus on entire populations, not on individual patients.” While private actions play a role, government is an essential actor. Those of us in public health often work in, or through government. We need to heed the lessons of this week’s election, remembering the need to deliver excellent, accountable government service, to win public trust for public solutions, and to keep our eye on the prize—equitable, effective, high-quality public health action, and better health for all.
Demography in the headlines
The last couple of weeks featured an unusual event, not once but twice: national headlines about demography! Both stories followed high-profile scientific publications, and neither offered good news.
The first story is based on a paper in JAMA from the American Cancer Society. U.S. mortality rates, which have been declining for decades, have slowed their decline in recent years. Between 1969 and 2013, mortality fell for heart disease (by 68%), cancer (by 18%), stroke (by 77%), diabetes (by 17%), and unintentional injuries (by 40%). But in the last few years of that period, up to 2013, the decline in mortality from heart disease, stroke, and diabetes slowed considerably. Could this be an effect of the obesity epidemic? Could it be that the benefits of therapies such as statins has “maxed out?” Could the financial crisis, rising income inequality, and resulting stress be responsible?
The second story, based on a paper in PNAS by economists at Princeton (including Nobel laureate Angus Deaton), may shed some light. It documents not just a plateauing, but rising morbidity and mortality in one subset of the U.S. population: middle-aged white people. The authors found, during the period 1999 to 2013, significant increases in self-reported poor health, pain, difficulties with activities of daily living, and heavy alcohol consumption. During this same interval, mortality increased from drug and alcohol poisoning (much of it opioid overdose), suicide, and chronic liver disease. Almost all of the mortality increase was concentrated among those with a high school education or less. Obesity accounted for very little of these findings. Could the economic and social trends of recent years, such as the rapidly falling incomes of households headed by high school graduates, account for these findings?
Two years ago, a report from the Institute of Medicine documented what it called “the U.S. health disadvantage”—the fact that our national health statistics fall far short of those in other nations, including many nations that are far less wealthy and that spend far less on health care. As our own Steve Bezruchka has eloquently explained, we are losing the health Olympics, and by a wide margin. These two new reports not only offer insights into these lamentable trends, but they focus attention on one of our School’s strategic priorities, the Social Determinants of Health, and emphasize the importance of upstream factors that affect how we, as a nation, suffer and die.
Food
Two of my favorite articles this month appeared in two of my favorite public health journals: Foreign Affairs and the New Yorker. The first, by former UN Secretary General Kofi Annan and former Gates Foundation official Sam Dryden, discusses improving Africa’s food system by connecting smallholder farmers to technical know-how, appropriate seeds and fertilizers, and markets. It recognizes that agriculture is about more than producing calories; it’s about changing society. To that end, it sets out five principles: valuing smallholder farmers, empowering women, focusing on food quality as well as quantity, creating a thriving rural economy, and protecting the environment. I found this an inspiring framework.
The second, by Dana Goodyear, explores the potential of seaweed as a major source of food. Goodyear argues that seaweed is the "culinary equivalent of an electric car”—one of the world's "most sustainable and nutritious crops," with a negative carbon footprint. We clearly need innovation if we’re to feed the world’s growing population, especially with degraded cropland and rapidly advancing climate change. Eating seaweed, like eating insects, may be one of those scalable, workable innovations. I’ll try it if you will!
Where have I been?
I attended two meetings this month. The first, hosted by the American Association for the Advancement of Science and the Carnegie Institution for Science in Washington DC, marked a remarkable event: the 50th anniversary of the first official warning to a U.S. President that continued fossil-fuel burning would “almost certainly cause significant changes” and “could be deleterious from the point of view of human beings.” The science has advanced a great deal in the last 50 years, bearing out this early warning. My role was to describe what we know about the health impacts of climate change. Want to see what I said? It’s online at http://www.aaas.org/climate50; my presentation begins at 2:16.
I also attended the American Public Health Association meeting in Chicago, as did many from our School. I presented in two sessions, one a panel discussion on health aspects of climate change, moderated by New York Times writer Andy Revkin, the other a talk on the role of higher education in addressing climate change and achieving sustainability (at which I showcased UW’s award-winning sustainability efforts). Let me know if you’d like to see the slides from this talk.
My next Dean’s Dispatch will come after Thanksgiving. In the meantime, please don’t hesitate to be in touch. I wish you a safe, happy Thanksgiving holiday with friends and family.
Howie
Howard Frumkin, M.D., Dr.P.H.
Dean, School of Public Health