As the November, 2020, US presidential election approaches, applying a public health lens should be a decisive factor in the minds of American voters. The upcoming election plays out against the backdrop of the COVID-19 pandemic, a public health emergency that is exposing entrenched inequalities. For the next US Administration, the challenge ahead is considerable, but with its unique resources and potential, there could be an opportunity for the country to put the right to health, health equity, and social justice at its core.
Over the past 6 months, the USA has been deeply affected by the COVID-19 pandemic—despite representing only 4% of the world's population the USA has recorded 22% of confirmed COVID-19 infections, with an estimated 6·5 million reported cases and more than 194 000 deaths, as of Sept 14. The current government has drawn wide criticism for its handling of the COVID-19 response—from dismissing and downplaying the seriousness of the illness to contradicting public health messaging and scapegoating WHO and China. This crisis has also magnified the health vulnerabilities within the population—with its impacts clustering according to the underlying burden of non-communicable diseases, socioeconomic disadvantage, and ingrained racial divisions.
Although the USA spends more than 16% of its gross domestic product on health care, in the past decade, increases in life expectancy have stalled. The most common causes of death are ischaemic heart disease, Alzheimer's disease, lung cancer, stroke, and chronic obstructive pulmonary disease; and the top three risk factors are high body-mass index, tobacco use, and high blood pressure. All mostly preventable and modifiable.
In this issue of The Lancet Public Health, Howard Bolnick and colleagues used data from the Global Burden of Disease Study to estimate that US health-care spending attributable to modifiable risk factors was US$730 billion for 2016, corresponding to 27% of total health-care spending. Most of the spending on preventable illness was due to five risk factors: body-mass index, high systolic blood pressure, high fasting plasma glucose, dietary risks, and tobacco exposure. Such analyses highlight the need for preventing and controlling risk factors. A new government has an opportunity to intervene through evidence-based public health solutions that have proven effective in other countries.
The future of health in the USA is not only an issue of individual risk factor exposure, but one of social justice too. Health disparities according to individual and geographical socioeconomic status, race, and gender are far too common. Access to health care is a key determinant and a clear dividing line in the election. Despite the Patient Protection and Affordable Care Act (ACA) adopted in 2010, 30 million Americans do not have health insurance coverage. For the 2020 election, the Democrats' party platform proposes expanding access to health care by extending ACA and Medicare coverage, whereas the Republicans are expected to further challenge the ACA and devolve more health-care decisions to the state level and private sector provision. Universal health coverage, a key lesson of the COVID-19 pandemic, is crucial to the health of a nation.
The health of Americans is plagued by unaddressed social, racial, commercial, and political determinants of health. In a series of Comments published in this issue, public health leaders and researchers paint a bleak picture of the current situation and articulate their hopes for the next election. Alexander Tsai and Atheendar Venkataramani call on the next administration “to enact structural changes to ensure that the patterns of the past are not repeated in the future.” For Matthew Kavanagh, there is a clear need for a “new solidarity-focused pandemics initiative”. For Esther Choo and Aaron Carroll, “from a health perspective, the upcoming US election could be the most consequential in our lifetimes.” They see two choices for the 2020 candidates: “Either they can deny the effect of the COVID-19 pandemic, and both the immediate failures and structural forces that let it play out so disastrously in the USA, or they can accept that we need change and articulate a real plan for it.”
The devastating health, social, and economic impacts of the pandemic, and its response, especially for the most vulnerable, cannot be underestimated or ignored. COVID-19's effects could last for decades—yet they do not need to have catastrophic health, social, economic, political, or international consequences. What happens on Nov 3 will dictate the success of the USA—and, indeed, the world.
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