A Public Health of Consequence: Review of the November 2016 Issue of AJPH

Where should a public health of consequence focus its energies? We have previously argued in these pages for public health to focus on the ubiquitous factors that shape the health of populations. Although this call is not new, and echoes a broad range of work in other publications,¹ it continues to present a challenge for public health. The social, cultural, and economic forces that shape population health mostly reside outside of the remit of public health, making it a challenge for the field to embrace points of intervention where public health can plausibly make a difference.

SCHOLARSHIP AND PUBLIC CONVERSATION

How, then, does public health rise to this challenge? We suggest that public health may do this in two ways. First, public health stands to generate scholarship that documents the role of ubiquitous, large-scale determinants in shaping population health. This provides evidence that can in turn be used by advocates and those who can make change happen, whether they are within the typical bounds of public health as a discipline or not. Second, public health can and should engage in efforts to shift the public conversation. Such efforts aim to clarify the role of the foundational conditions that shape health in public consciousness, and can move us beyond an individual curative perspective that ultimately distracts from efforts to change the conditions that make people healthy. In some ways, both of these approaches are intertwined, because the former (the generation of scholarship in the area) is a precondition for the latter (the translation of that knowledge into information that can guide effective action). Three articles in this issue of AJPH offer examples of scholarship that combine these approaches and can help set the stage for action that improves the conditions that make people healthier.

LEAD AND HOUSING

First, Ahrens et al.² use data from the National Health and Nutrition Examination Survey to assess blood lead levels among children aged one to five years living in housing assisted by the Department of Housing and Urban Development (HUD). This article shows that children in HUD-assisted housing had lower blood lead levels than children who did not receive housing assistance. These findings appear to reverse 20-year-old findings that there was a higher proportion of children with high blood lead levels among those residing in public housing compared with those not residing in public housing developments.³ While the authors are suitably cautious in interpreting the findings, this study provides early evidence of the effectiveness of The Residential Lead-Based Paint Hazard Reduction Act of 1992 (Pub L No. 102–550), mandating lead-based paint inspections and lead risk assessments for those living in housing that received HUD financial assistance. It shall take more work to definitively document this relationship, but Ahrens et al. take a promising first step toward showing how policy implementation can, over decades, contribute substantially to the improvement of population health.

HIGH RENT AND HEALTHY EATING

Second, Basu et al.⁴ use data from the National Household Food Acquisition and Purchase Survey to show links between cost of housing—particularly high rent—and healthy eating, and that living in a higher-cost county was associated with an 11% lower Healthy Eating Index. Importantly, Basu et al.⁴ show that the Supplemental Nutrition Assistance Program mitigated some of the impact of high-cost living on poor nutrition. In some respects, there is nothing surprising about this analysis: living in a county where more of one’s resources go toward housing stands logically to detract from one’s capacity to purchase more costly nutritious foods. However, the power of the analysis lies in its simple and effective demonstration of the ubiquity of economic conditions, and the programs that may mitigate their income. Housing is a public health concern, and this analysis shows just one way in which housing and its attendant costs are an important driver of one of the most pressing challenges of our time: poor nutrition and its attendant chronic disease.

MARIJUANA LAWS AND BLOOD OPIOIDS

Third, Kim et al.⁵ look at a different issue altogether, considering the potential relationship between state-level medical marijuana laws (MMLs) and opioids detected among injured drivers. There has been, not surprisingly, substantial controversy about MMLs in the United States. The analysis by Kim et al.⁵ builds on previous work that has shown that MMLs are associated with lower opioid overdose mortality rates⁶ and suggests a plausible mechanism for this previous observation; namely, that in states with MMLs, fewer people are using opioids. The authors are careful to note that this observation remains preliminary and that it may not have bearing on the introduction of laws that legalize marijuana for recreational purposes. However, this article serves as another good illustration of work that assess how changes to the political conditions that structure our lives can result in changes to our collective health, both bearing witness to these changes and providing data that can be used to inform the political to-and-fro that ultimately results in the allocation of resources toward social investments, including ones that promote the health of populations.

TRANSLATING RESEARCH INTO POLICY

We are perhaps acutely attuned to the factors that inform political decisions as we write this, conscious that when this piece is published we will, in the United States, be a short time away from having a new president-elect, setting the stage for a new administration. We see it as the role of public health in this transition to agitate as much as we can for political decisions and investment that best promote the health of populations, and much of that will have to come through growing awareness that it is the full range of social, economic, and cultural factors, all shaped by large-scale politics, that ultimately must be optimized to produce population health. We also close with a nod to the essay by Ahern et al.⁷ in this issue of AJPH, which focuses on the utility of population intervention parameters that can help bridge the gap between research findings and policy. This article provides a compelling argument for the provision of measures in our work that are readily interpretable for those who are in a position to shift policy. Ahern et al. suggest that “more widespread use of this approach would improve the translation of research results to practitioners and provide a more realistic sense of the magnitudes of changes in the outcome that could be expected from interventions on the exposure under study for different populations of interest.”^(p1943) We could not agree more and look forward to more articles in AJPH that adopt this approach. We would see this as entirely consistent with the agenda we are proposing here, one that engages population health scholarship with the conditions that foundationally make people healthy.