Wisdom//

What We Need to Talk About When We Talk About Health

The Dean of Boston University School of Public Health on what the election results mean for health care in the United States.

The midterm elections are over and the results are in many ways unclear. The vote was expected by some to deliver a decisive verdict either endorsing the direction of the country as led by President Trump or repudiating this course with a dynamic “blue wave” of Democratic victories. The actual result was more akin to a split decision. Republicans expanded their control of the Senate, while Democrats made significant gains in the House of Representatives, winning control of that body. With each side plausibly claiming a “win,” it is nevertheless a win tempered by uncertainty.

There was, however, one clear winner last week: health. Many will read this and think I mean health care, and, in a sense, I do. Health care was central to many winning campaigns; across the country, voters endorsed calls for Medicaid expansion, protection for people with preexisting conditions, and, in some places, single payer health care—an idea once deemed radical in the US that has since garnered mainstream acceptance.

But health means far more than just health care. Health care provides us with the treatment we need when we are sick. Health, however, is a product of the social, economic, and environmental conditions in which we live. These conditions decide whether or not we get sick in the first place. They include education, income inequality, workplace safety, environmental regulation, climate change policy, and housing. After all, we cannot live healthy if our air is polluted, our schools neglected, our economy unjust, our planet burning, our neighborhoods unsafe, or our children threatened by a society bristling with easily-accessible guns. The policies that affect these conditions are determined at the political level. In this sense, it could be argued that our Congressional representative is as important to our health as our doctor, or even more so. In selecting our representation last week, we were not just making choices about our government. We were making choices about our health.

Happily, across the country, voters chose health, embracing a political vision that is broadly supportive of the conditions that promote health in our society. From a Washington state ballot initiative raising the legal age for purchasing assault rifles, to an Arkansas measure raising the minimum wage, to Massachusetts overwhelmingly rejecting a ballot initiative that would have stripped civil rights protections from transgender people and made them vulnerable to harassment and assault, voters made clear they want a country that is safer, more inclusive, less economically stratified, healthier.

Americans were able to make this choice at the ballot box because they first made an even more fundamental choice, in their homes and communities, to collectively demand health. Indeed, to borrow a phrase from medicine, if there has been one “side effect” of the Trump era, it has been Americans’ increasing willingness to advocate for health. This initially stemmed from the response to Republican efforts to repeal the Affordable Care Act. Americans, in contrast with many other economically comparable countries, have long been ambivalent about the concept of universal health care. This was clear in the fierce resistance to the ACA, sustained over the course of nearly a decade, which led to many of the Republican electoral gains that last Tuesday rolled back. Faced with efforts to repeal the law, however, Americans mobilized to defend health care, acting not as mere special interests advancing a policy, but as citizens standing up for a core value, a right. This activism has since extended to the broader conditions that shape health. More and more, we are treating issues like climate change, economic inequality, and gun violence as public health issues, and have begun to address them with the same fervor that characterized the introduction of vaccines or the early fight against AIDS. It is personal now, because we understand that our health is at stake, and without health, we have nothing.

This change in how with think about, and fight for, health did not emerge spontaneously. It started with shifts in the national health conversation. We could not treat gun violence as a public health issue until we started talking about it as a public health issue. The same goes for other subjects that have little to do with health care and everything to do with health. We first need to see the connection to health, name it in our national dialogue, and then we can act.

It was with this in mind that I wrote my new book, Well: What We Need To Talk About When We Talk About Health. It examines 20 core forces that underlie health in the US. Money, power, politics, housing, place, public goods, pain and pleasure, love and hate—these are some of the subjects we need to address if we truly wish to be healthy. Each chapter explores one of these themes, with the goal of informing the national conversation about health, as we lay the foundations for a healthier world.

The election, as encouraging as it was for health, was only a single step in our progress toward such a world. This journey began generations ago, with improvements in living standards brought on by the Industrial Revolution and early public health efforts to improve sanitation and eliminate disease. We have since broadened our understanding of the forces that shape health beyond the biological, to see how our social, economic, and environmental context can undermine health or help it thrive. As this understanding continues to evolve, we must apply the lessons of our own time to the business of promoting health at all levels of society. In order to do this, we must change what we talk about when we talk about 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

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