By Ana V. Diez Roux, MD, PhD, MPH

The end of the year is always a time of reflection, a time we yearn for a fresh start, turn over a new leaf, look forward to a new beginning. This year I would hazard to guess, this feeling is stronger than ever. The year 2020 is a year none of us thought we would live through, a year in which the world was changed in ways that none of us could have predicted. It is likely to be a year that future historians will look back on as we look back now to 1918 (the year of the flu pandemic) or 1930 (the year of the Great Depression), years that marked generations for their lifetimes. And perhaps, we will see this as a time when big changes began to happen, an inflection point, a time of reckoning and darkness but also a time when new possibilities, and a new light, emerged.

Our vision of public health for the future, intertwined as it is with our society, its history and how it is organized, will of course be profoundly affected by 2020. How it will be changed is difficult to predict and there is no guarantee that the change will be positive. But it is also true that 2020 has in many ways put public health at the center of public debates, of social movements, and of politics like never before in our lifetimes. In these discussions, in these movements, in this new recognition of how our health and our society are entwined, three overarching challenges have emerged that represent opportunities for public health globally, next year and beyond.

First, the year 2020 has vividly highlighted the critical role of governments at all levels, from cities, to states, to nations, to intergovernmental organizations in monitoring and safeguarding the health of the public. Although this may seem obvious to many of us in public health, it is by no means accepted fact as reflected in the underfunding of public health agencies and infrastructure, not only in United States but also all over the world. But 2020 has also highlighted how the role and the responsibility of governments in public health goes beyond supporting the traditional “public health functions” like monitoring infectious disease, contact tracing, and delivering vaccines, important as all these functions are. We have also seen stark illustrations of the critical role that government can play (or unfortunately fail to play) in providing income support to the unemployed and assuring a minimum wage, in preventing evictions, and in eliminating police brutality and racism in law enforcement. These are just some examples of how the broader actions of governments have profound impacts on population health. The pandemic has also painfully highlighted the critical importance of coordinated government action, not just across jurisdictions within countries, but also across countries themselves, as reflected in the growing calls (not always listened to in these times of growing nationalism) for coordinated global action by intergovernmental agencies in controlling the pandemic and delivering vaccines. 

A second challenge highlighted by 2020, is of course, the need to act to eliminate the structures, systems, and policies that create profound social inequities and that have sustained the long history of racism in the United States and in countries all over the world. It has been remarkable to see the public discussion of health inequities that has been stimulated by the pandemic. In parallel, triggered by repeated police killings of Black people in the U.S., and strengthened by the Black Lives Matter movement, social movements worldwide have called for an end to the racism embedded in so many aspects of our society. Racism has been explicitly recognized as a public health crisis not only by activists and public health leaders but also by traditional medical societies such as the American Medical Association. Transforming these statements into real change will not be easy and will have to overcome many obstacles. But there is a sense that despite all the hardship, 2020 may have created an opening to recognize and address the fundamental drivers of structural inequities by race, class, and geography within and between countries. This is critical to promote health, but in an interesting twist, the visibility of health inequities has reinforced the moral imperative for social justice which has meaning regardless of any health implications.

Last but not least, the third challenge highlighted by 2020 has been the critical and urgent need to finally take seriously how our economic system and our way of life (especially the way of life of us the wealthy in the wealthy countries) is affecting our environment and our planet. The pandemic has shown us how a life with less travel is possible, what cities without private cars and more pedestrians spaces would feel and look like, and how carbon emissions and air pollution levels can drop dramatically in response to our actions. Growing discussions and movements about how to “build back better” have implications not only for how cities are designed and managed (retaining the many health-promoting aspects of high density and active travel) but also for how our economy is organized and even for the values and the type of economic activity that we prioritize. These larger questions are closely related to the other two challenges of leveraging the power of government action and eliminating structural inequities. A different way of life cannot emerge without government intervention and regulation. And our failure to address the environmental consequences of our system is contributing to and reinforcing racial and social health inequities, as has been historically highlighted by the environmental justice movement and increasingly by the documentation of how climate change is impacting the most disadvantaged globally.

Sometimes I wonder how 2020 will be remembered by my four nieces, Emilia, Olivia, Alisia, and Isabella, ranging in ages from 9 to 22 years and global citizens whose lives and families span Argentina, Brazil, Italy, and the United States. Will this year mark them forever or will it imperceptibly blend and disappear into the golden years of childhood, adolescence and young adulthood? In some ways I hope that they will always remember it, because if they do, it may mean that 2020 was the end of an old order and the beginning of a new era.