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Hard Times for Public Health

Posted on January 30, 2017

Over the past few weeks many of our students have asked me what the recent changes in the US political context will mean for them or for public health. What should they do as public health students? What will all this mean for the public health world into which they will graduate?

Much of the discussion on the health implications of the recent US election has centered on the dismantling of the Affordable Care Act (ACA). Whether one believes or not that the ACA is the best long-term solution to ensure access to quality care for all, it is clear that its implementation has signified a major improvement for millions of uninsured individuals. In our own city, Philadelphia, a recent brief produced by the Department of Public Health showed that the ACA has provided health insurance to 220,000 residents. The dismantling of the ACA will have implications for the health care access of millions of persons.

But the health implications of recent political events go well-beyond their effects on the ACA. Some of the effects are direct and obvious. The health consequences heat, floods, and other “natural” disasters resulting from climate change are well established. Evidence-based environmental regulation has resulted in major reductions in air pollution exposures known to cause many adverse health events. The availability of family planning has had a major impact on the health of women and children worldwide. Housing policies have improved the health of children by contributing to the reduction of asthma and lead poisoning. Aid to developing countries has reduced infectious diseases, protecting not only the developing world but also the United States itself. It is not hard to predict that a rolling back of policies related to climate, environment, family planning, housing and foreign aid may have major long-term health consequences.

Yet there are other more subtle but pervasive consequences including the sense of threat and insecurity generated by the discourse and recent actions against immigrants, and more generally the questioning of a fundamental societal commitment to equity, social justice, and inclusion. Aside from the obvious health implications of refusing to accept refugees or others fleeing violence and economic hardship, even just the threat of deportation can have important public health consequences. Immigrants who feel persecuted may reduce their use of health care with possible consequences not only for them but also for the community at large. And research has documented measurable impacts of immigration raids or other forms of intimidation on health, including birth outcomes, likely mediated through stress pathways. Social exclusion has many documented adverse health consequences, the opioid epidemic being just one recent example. And then of course there is the pervasive sense that facts and evidence don't matter anymore. If there are no facts and no scientific basis for public health action then all is opinion, arguable and relative. And the basis for rational public health action disappears.

Given all of this, when our students ask me what they should do, I have to say that for the first time in many years I have found it hard to come up with convincing answers. There are so many challenges, it is tempting to throw up one’s hands in despair. But then I remember what got me into public health to begin with: a desire to create a society that will ensure the conditions necessary for everyone to have a healthy and fulfilling life. This means a commitment to science, action, and equity; to showing the links between how society is organized and health, and acting to improve health for all.

Today, sustaining the values of science and equity and making them a reality is more important than ever. So my answer becomes a simple one: return to the core and the guiding principles. Do what public health has always done: understand, advocate, and act.