A Public Health of Consequence: Review of the February 2017 Issue of AJPH

We are on the cusp of a new administration in the United States, led by President-Elect Donald Trump. It is then impossible not to reflect somewhat in this Public Health of Consequence commentary on the potential impact of this election on the public's health.

AN ELECTORAL TRANSFORMATION

The United States has just gone through a remarkable electoral transformation, both symbolically and substantively. Symbolically, the country went from the first elected Black president to a president who drew at least some support from groups that were subtly racist at best, and explicitly racist at worst. It went from having an administration that governed for eight years without any major personal scandal to a president who was engulfed in accusations of sexual harassment of women during this presidential campaign, and whose own words and amply recorded actions are evidence of nativism, misogyny, and racism.¹ There is abundant reason to be concerned with the potential implications for public health of this shift in presidential symbolism, language, and action. AJPH and all the leading journals in the field have long published scientific articles showing the untoward health consequences of racism and sexism,² and the link between language that inspires hate and the worsening health of the population.

EXPECTED DOWNTURN IN POPULATION HEALTH

Substantively, there is equally abundant reason to worry that the Trump presidency represents a threat to the health of the public. We have written in this column repeatedly about the imperative for public health to engage with the social, economic, cultural, and political determinants of health, seeing those issues as bedrock foundations for the production of the health of populations. The new administration was elected on explicit challenges to many of these conditions. It is almost inevitable that the new administration will adopt regressive taxation policy that will deepen income, social, and health divides. The new administration was swept into power in no small measure on calls for toughening our stance on immigration, threatening the deportation, or at least the denial of entry, of millions—clearly affecting their health. And, the animating intellectual force behind the new administration’s social policies are steeped in conservative thinking that aims—in no small part through sculpting the composition of the Supreme Court and other levels of the judiciary—to challenge social and cultural forces including LGBTQ (lesbian, gay, bisexual, transgender, and questioning) rights among many others. There is much scholarship to be done to document the impact of this right turn in the country’s politics on the health of its population, but there is reason to believe at the outset that we are possibly entering a period of a downturn in population health. We note that the last time the country took such an abrupt shift to the right, with the election of Ronald Reagan in 1980, we reversed population health gains and set ourselves on a course, over the past 35 years, where we now lag substantially behind our peer high-income nations in all leading heath indicators.³ This does not even begin to address the incoming administration’s promise to dismantle the Affordable Care Act, a signature piece of legislation that has successfully provided health insurance coverage to nearly 20 million people.

It also bears mentioning that the anticipated social and economic changes that will emerge under President Trump will almost certainly widen the divide between health haves and health have-nots. It is ironic and sobering that President Trump came to power on a wave of public discontent fueled, in no small part, by the sense of neglect experienced by large parts of the population that carry a far higher health burden than much of the rest of the population. We would expect that in the coming four years, our social divides and health divides both will deepen, unfortunately reinforcing each other.

POPULATION HEALTH SCIENCE

With that said, this issue of AJPH includes an editorial by Bachrach and Daley⁴ about the key challenges faced by population health science (PHS) that we think echo well the pressing challenges of our time, reflected previously. Bachrach and Daley are concerned with the challenges we face in integrating the study of macro-social processes in the work of public health, and the equally daunting challenge of bridging the scholarship–action gap. Both concerns are indeed valid, and both become pressing needs in a time of greater challenge to the health of populations. We note here that we shall need careful and thoughtful scholarship to document the consequences of the new administration’s actions, not only to understand how political decisions affect health, but, perhaps more importantly, to understand how we may mitigate them. Bachrach and Daley are correct in identifying this as both a core challenge and perhaps an opportunity for population health science. Recognizing and narrowing the gulf between the generation of scholarship and action remains a chronic concern throughout the academic community and is perhaps more visible for a pragmatic field like public health—pressingly so in the face of a political shift that stands to threaten the health of the public. Recent years have brought welcome and visible efforts, such as the Robert Wood Johnson Culture of Health initiative, that have been concerned with bridging the gap between thought and action. We concur that this becomes an abiding motivation for population health science and are grateful to Bachrach and Daley for articulating it.

Importantly, Bachrach and Daley also announce the emergence of a new professional society (the Interdisciplinary Association of Population Health Science) that gives PHS a societal home and will help fuel some of the initiatives discussed here. This is clearly a welcome development and represents an important opportunity for the field, perhaps needed now more so than ever.

FOUNDATIONAL DRIVER OF HEALTH

Finally, several articles in this issue of AJPH tackle some of the foundational drivers of health and illustrate the forces of consequence that shape the health of populations. In particular, we draw the readers’ attention to the article by Kim et al. about childhood maltreatment⁵ (perhaps the most consequential form of traumatic event, setting populations on an adverse life course trajectory of poor health) and the article by Ramsey et al. on the mental health consequences of conflict from our ongoing wars in the middle east.⁶ We shall in future columns consider, through the lens of articles in each issue of AJPH, how our national political landscape is evolving, and how the health of the US population is shifting as a consequence.