Each January, we make guesses about the people and things we think you’ll be talking about in the New Year.
Our first pick for 2015 is the idea that whole neighborhoods—homes, workplaces—and some laws—should be deliberately designed to promote health. Experts use the phrase “Health in all Policies.”
“Public health is working with transportation, with housing, with agriculture, with education, with the justice departments, really with anyone who makes decisions that impact what a community looks and feels like,” said Linda Rudolph, director of the Center for Climate Change and Health at the Public Health Institute.
The term “Health in all Policies” is pretty esoteric, but the influence of public health is all around. Often, though, it goes unnoticed.
Examples of “Health in All Policies”
If the concept did have a sound it might be the blaring alarm of a home smoke detector. Every home is supposed to have fire protection. It’s the law, and somewhere along the way public health experts pushed and lobbied for that rule.
Car seatbelts are another example. It’s hard to remember a time when they weren’t standard issue—and required by law–but at first, mandatory seatbelts were a big fight.
In most places there are rules against smoking in public places. Lead paint is banned in homes. Those are all obvious, widely accepted, public-health protections.
Now there are debates about all sorts of other things that public health people say might matter to your health–-from playgrounds and farmer’s markets–even the number of trees in a neighborhood, to how you get to work each day.
“If we make even modest shifts in how we move around in our communities toward walking and biking and using public transportation, instead of driving, we get huge health benefits,” Rudolph said.
Making changes beyond the health sector
Georges Benjamin is executive director of the American Public Health Association.
“We think if you really want to make a difference in health, it all cannot happen just within the health sector itself,” Benjamin said.
It turns out that what happens in hospitals and at the doctor’s office contributes a relatively small amount to good health, he said.
Genetics is part of the equation, plus – another esoteric term from the public health experts: social determinants of health: “It’s all these things in the environments where we live, work, study and pray that really determine our individual and our community health outcomes,” Rudolph said.
But at what cost?
Critics worry that regulating those things is expensive, and may slow down progress by adding bureaucracy.
“We hear that a lot,” Benjamin said. “Because what often happens is the health people get brought in too late in the project. When they are about to lay the concrete is not the time to get involved in a project or when they’ve already drawn up the plans.”
Benjamin says it’s important to tally not just the upfront cost of a public-health policy, but also count up the savings that may come down the road.
If you’re designing a street for example, adding a bike lane is extra money. But Benjamin says there’s also a health-care cost when a cyclist zips in and out of traffic and gets hit by a car. At the population level, society saves money when pedestrians can cross the road safely, Benjamin argues.
Linda Rudolph helps local groups in California integrate the concept of “Health in all Policies” into whatever mission they are trying to accomplish. She’s always on the lookout for ‘co-benefits.’
“All of these different specialists speak different languages and what we’ve found is that when you put people in a room and learn what each other’s language is, a lot of the early misunderstandings fall away,” she said.
“I was in a meeting recently with people from a number of different agencies, where the planners had developed a plan for a light rail station and when the health and public works folks looked at the plan, it was quickly evident that there was no way for bicycles to easily get to the train station,” Rudolph said.
Rudolph prefers to have those conversations early.
“We don’t see Health in all Policies as tying anyone’s hands. In fact we think it’s more efficient and effective for different sectors to work together, so they aren’t working at cross purposes,” she said.
Sometimes the push for “Health in all Policies” causes pushback. Recently lawmakers in Congress expressed concerns that nutritionists helping to revise the national nutrition guidelines were gathering information on the environmental implications of different food choices.
The connection between the environment and health makes sense to Linda Rudolph.
“If we eat less meat we reduce methane emissions from livestock production, and we get health benefits from eating less meat, so there’s many examples of co-benefits,” she said.
She and other supporters of “Health in all Policies” also see a link between climate change and health.
“For example we know that low-income and people of color have higher rates of chronic disease like diabetes or heart disease and that makes them more vulnerable to heat illness during extreme heat events,” Rudolph said. “Low-income neighborhoods are also more likely to have urban heat islands because of density and the lack of trees and green space. Those urban heat islands can be 12 to 20 degrees higher during a heat wave than surrounding neighborhoods, that’s another factor that puts people at higher risk.”
Can public health measures go too far?
Skeptics say that concept: “Health in all Policies” can go too far when advice from public health gets codified and hard baked into the law. For proof, Walter Olson from the libertarian think tank The Cato Institute looks back 100 years to Prohibition.
“I think Prohibition was a disastrous experiment that the country should have never have entered,” he said.
Olson said prohibition was partly sold as a public-health measure. It was supposed to prevent illness and curb violence, but the national ban on alcohol also had unintended consequences such as bathtub gin and bootlegging.
“Doctors are not the only ones we need to listen to and sometimes we want the freedom to lead our lives even in ways that may not follow doctor’s orders,” Olson said.
He’s pretty dubious about New York City’s ban on super-sized drinks, and he’s iffy on mandatory nutrition labels at fast-food restaurants. Those solutions are too simple, Olson says, to fix our very complicated obesity problem and like Prohibition, he said, public health policies might have un-imagined consequences.
The science is still developing on whether menu labels nudge people to make lower-calorie food selections. Still, the Obama administration will soon require chain restaurants and vending machines to display calorie information, and some cities, such as Philadelphia, already have similar rules.
“Although certainly some people are adjusting their behavior, there was one study that found that some groups, particularly younger men seemed to be ordering more calories once the calorie levels were displayed because they were lead to more efficiently grab the large number calories that they wanted,” Olson said.
Believers and opponents, Just You Wait, we think lots of people will be talking about “Health in all Policies” issues in 2015.