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

In an article published in this issue of AJPH, Egen et al.¹ demonstrate the impact of poverty on various health outcomes and social conditions by comparing America’s poorest counties to both America’s richest counties and to other countries in the world. In doing so, the authors show us simply, graphically, and effectively, how these two sets of observations literally map onto the state of the country today, and why a public health of consequence can ill-afford to ignore poverty as one of the core drivers of poor health in US populations. Using five-year averages for median household income, the 3141 counties in the United States were formed into 50 new “states”—each representing two percent of America’s counties (62 or 63 counties, each). This article compares the poorest and wealthiest “states.” Using this simple—but highly effective—approach, the authors find dramatic and statistically significant differences in life expectancy, smoking rates, obesity rates, and almost every other measure of health and well-being between America’s wealthiest and poorest “states.” Perhaps most remarkably, they show that more than half the countries in the world have a longer life expectancy than Americans living in the poorest “state.” When the authors compared these new “states” to cross-national data they found that among 222 countries, life expectancy for the United States’ wealthiest “state” would rank 8 and 25, respectively, for men and women, while life expectancy for the poorest “state” would rank 123 and 116 for men and women, respectively.

Over the past decade, the United States has witnessed a dramatic increase in the concentration of poverty across the country. The number of people living in high-poverty neighborhoods has nearly doubled since 2000 (compared with an approximate 10% increase in the overall population), rising from approximately 7.2 million to 13.8 million,² with the number of high-poverty census tracts also doubling from about 2000 to 4000. We have gone from 2.4% to 4.4% of Americans living in extremely poor neighborhoods. This growth of poverty as a condition of daily life for ever-more-millions of Americans is, as might be expected, not evenly spread, neither across the country nor among groups within the United States. More than one in four Black poor and one in six Latino poor Americans live in high-poverty neighborhoods, compared with one in 13 poor Whites. Poor children are more likely to live in high-poverty neighborhoods than poor adults, and much of the growth in concentration of poverty has not taken place in the largest US cities, the cities that attract most of our attention, but in the midsize metropolitan areas (population of half a million to a million people) that characterize where most Americans indeed live.

Abundant evidence has shown that the United States is characterized by substantially worse health indicators than comparable high-income peer nations. On most criteria, health in the United States ranks last when compared with these peer nations.³ Of note, and frequently forgotten, it was not always thus. As recently as 1980, US health indicators were approximately in the top half for our peer nations. Over the past 35 years, health overall has improved, but our rate of improvement has lagged substantially behind that of peer nations, bringing us to the very bottom of the list in terms of health achievement. This is in conjunction with our spending much more on medicine (vs say prevention) than any of these other countries,⁴ putting the United States in the awkward position of spending more and achieving less on health—truly a poor return on our investment.

These observations stand as a remarkable reminder of the extreme socioeconomic disparities that exist in the United States, and how these disparities map onto our national health achievement. They suggest to us that a public health that is concerned with consequences—with our achievement of better health for populations—simply cannot ignore the issue of poverty, but rather must grapple with the issue as core in the production of health of US populations. It is worth remembering that public health has, appropriately, long been concerned with the poor, and efforts in Europe in the mid-19th century to improve health centered around improving conditions for the working classes who lived in abominable conditions, conditions resulting in repeat epidemics of diseases like cholera and tuberculosis. A call, therefore, to engage with issues of socioeconomic marginalization and poverty as an ineluctable cause of population health is in many ways a return to the very roots of public health. That we have to return to these foundational roots more than a century and a half after the birth of the formal roots of public health reflects broader macroeconomic trends that are well beyond the scope of this commentary. However, the responsibility of public health is clear: we must engage with the issue of poverty in the first half of the 21st century, both domestically and globally.

Lastly, in an essay also in this issue of AJPH, Resnicow et al.⁵ suggest a taxonomy for behavioral interventions, considering their likelihood of success on dimensions of difficulty and motivation, that may help us understand the efficacy of these efforts. In an era of diminishing public health dollars, and ever-expanding menu of available interventions, this framework could help public health researchers match available interventions to the readiness of the person, and the degree of difficulty of the behavior change sought. We are generally skeptical of claims of many behavioral interventions, as reading the evidence suggests that most such interventions have relatively little impact⁶ in the long term, absent a change in the foundational conditions that shape health. However, in the context of limited effectiveness, an approach to systematically understand what may work, and what may not work, seems a positive step forward to help systematize our investments, and one would hope, in the longer term, to bring about more rigorous evaluations of the long-term consequences of behavioral interventions.