Elevating the Value of Health to Guide Decision-Making in the Long Term

We are now in the second year of health dominating the public conversation. Since the beginning of 2020, when reports of COVID-19 began emerging and the threat of worldwide transmission became clearer, the world has been galvanized by actions taken to protect the health of the global population. This is unprecedented. Although there have been previous pandemics—the 1918 flu pandemic is, appropriately, often compared to the COVID-19 pandemic—none before has occurred in an era when communication technology has made the world as small as it is today, when anyone can be aware of changes in hospitalization rates anywhere in the world. We are living in a time of extraordinary visibility of health as an animating, organizing concern for governments worldwide.

Before 2020, in this column we often commented on the importance of elevating the value that we, as societies, place on health.¹ We did not imagine then that 2021 would be a moment when health has unequivocally vaulted to the top of the global agenda and has been the central motivation for a more than a year of decision making worldwide. Time-honored aphorisms about the centrality of health to our lives surged to the fore, and for more than a year now we have had very little meaningful public discussion questioning the global efforts to change how we live, work, and play in the name of protecting our health.

THE CENTRALITY OF HEALTH

That a health concern has so captivated the world suggests indeed that we value our collective health. This is enormously promising and points the way to opportunities for change in which population health becomes the fulcrum around which policy change is oriented. This has long been an aspiration of public health, embodied perhaps most clearly in the Health in All Policies movement.² If we are to think collectively about how to maintain the focus on health that has dominated 2020 and 2021 to sustainably create a healthier world, we may wish to better understand how much we value health and how that value can be translated into tangible action. The central question that emerges is whether we value our health sufficiently for it to inform our actions and decision making during times when we are not afraid of a novel pathogen with features that are only now being understood.

The pre–COVID-19 evidence on how much we value health was not exactly promising, as Farina et al. capture well in this issue of AJPH (p. 708). The authors document disparities in life expectancy, disability-free life expectancy, and disabled life expectancy among adults across the United States. They find enormous cross-state variability in disability-free life expectancy and disabled life expectancy, with more than a 6-year gap in the former and a 1.5-year gap in the latter when comparing the healthiest and least healthy states.

This analysis builds on a well-established body of work that shows substantial interstate variability in health and that has long shown that our collective health in the United States would be much improved if we adopted efforts uniformly that we know work well in some states. For example, Yoon et al.³ show that if all states achieved the lowest observed mortality levels among the healthiest states for the five leading causes of death, when considered separately, more than 90 000 premature heart disease, 84 000 cancer, 28 000 chronic lower respiratory disease, 16 000 stroke, and 36 000 unintentional injury deaths could be prevented each year. Importantly, analyses such as those by Yoon et al. and Farina et al. are not grounded in the expectation that we implement unattainable policies. Rather, they suggest that were we to do what we already know works, we would save a substantial number of lives and make many lives healthier. Critical for the topic of this column is the simple observation that we have not acted accordingly, despite knowing what we could do to make our lives healthier.

KEEPING HEALTH FOCUSED

What explains this paradox? Why do we transform the world we live in on, essentially, a moment’s notice when it comes to a new previously unknown pathogen although we have long acted as though health was not a top priority? Do we value health sufficiently to implement policies that consistently promote it even in nonpandemic times?

We suggest that the answer to this question is that our society has not engaged sufficiently with health as a core value so that it can guide action that promotes health when we are not in the midst of a pandemic. Ultimately, most experience health as an individual phenomenon that intersects with visits to health care providers; in the pantheon of those who promote health, this elevates doctors and nurses far above the politics and policies that ultimately play a core role in generating population health. When this is how health is experienced, we do not create the opportunity for health to provide the political ballast to drive policymaking. The COVID-19 experience is an exception—but one that reinforces this observation. The novel coronavirus threatened individual health, even if COVID-19 was perhaps the ultimate population health experience.

The lesson that emerges from the article of Farina et al. is that we have far to go to elevate health as a value that motivates policy and decision making. What the COVID-19 moment teaches us is that it is possible to elevate health but that to do so we need to reorient the global conversation so that it is clear that the health of all is interlinked and an important consideration at all times. Perhaps, equally importantly, we can elevate health by making it clear that health can be improved. After all, much of the COVID-19 conversation is about the fact that we can take action to mitigate the spread of the virus. The article by Farina et al., and others like it, shows that there is much we can do to improve our collective health. Our task now is to ensure that this is well understood and that the value we have placed on health throughout 2020 becomes a growing concern—one that can lead to better population health in coming years.