Accounting for the Full Scope of Health Consequences of Policy Decisions Across the Life Course

Our health is of immediate concern to all of us. Indeed, it is difficult to think of much that is of more immediate concern. Our health makes it possible for us to make choices about how we wish to live our lives. Clearly this statement is complicated by the many and varied expressions of health, and we recognize that many of us can live rich, fulfilled lives, even if in imperfect health. But fundamentally good health affords us the means to live however we wish, serving as a key element of our individual dreams and aspirations.¹

It is, then, not at all surprising that we tend to focus on health in the present. If we are unhealthy in the moment, it inhibits our capacity to do what we wish in the moment and compels us to seek a cure. This is when there is a synergy between our individual perception of health and the aspirations of medicine. Medicine is fundamentally concerned with restoring us to health, overcoming sickness in the short term so that we can return to living our lives as we choose to. That is a powerful and compelling aspiration and explains, in no small part, why we as a country spend more on health care, by far, than any other comparable high-income country.² A health concern is an urgent concern, and we, as a country, have long judged it worth it to spend as much money as we can to ameliorate that concern, resulting in extraordinary spending on our health care.

And yet, as readers of this series of commentaries well realize, despite our spending on health care, our health as a country lags substantially behind our peer nations. Central to the reason for this mismatch between health spending and health outcomes is our underspending on preventing illness and, commensurately, on lessening the structural forces that contribute to illness throughout the life course.³ We underspend on lessening these structural forces for many reasons, but perhaps first among those is that it is often difficult to see the direct link between those forces and our health. Although we may be able to recognize logically that, for example, spending on parks and recreation facilities will lead to opportunities for exercise and healthier populations in decades to come, that concern is readily drowned out by concerns with individual cardiac disease in the present, even if that cardiac disease could have been prevented with investment in structural forces in previous decades.

This, then, makes work that highlights the full scope of the life course a consequence of societal decisions that much more important. By documenting the health impacts of decisions in the present throughout our lives, such work builds on the scholarship of life course thinking^4,5 and bears witness to the forces that generate the sum of health over many decades and may help us focus on structural causes of health.

HEALTH CONSEQUENCES

Three articles in this issue of AJPH do just that. The first article, by Wang et al. (p. 2008), documents the long-term health burden of suboptimal diets, focusing on cancer. Starting in 2017, they studied a closed cohort of US adults aged 20 years or older, modeling events across the lifespan. They found that suboptimal diets contribute to 3.0 million new cancer cases, 1.7 million cancer deaths, and more than $250 billion in economic costs. The sheer scope of the consequences of suboptimal diets this study suggests is staggering, even more so when noting that many of the cancers studied were attributable to high consumption of sugar-sweetened beverages and low consumption of whole grains. Importantly, both sugar-sweetened beverages and diet composition are linked, relatively directly, to policy decisions that we make as a society.⁶ This means, in essence, that we are choosing foods available to us and thus choosing to incur the long-term burden of cancer over the life course. When stated in such stark terms, these choices may seem inexplicable but perhaps are less so in the broader understanding of our focus on the immediate in health and our challenge, as discussed here, with thinking of the long-term consequences of actions today for our health tomorrow.

Our challenge with thinking about, and working to prevent, untoward health consequences in future decades is illustrated well in the current COVID-19 moment and is shown in two other articles. COVID-19 gripped the country and the world starting in 2019. Efforts to mitigate the spread of COVID-19 have included a wholesale limitation of population mobility, limiting employment for many, and limiting access to routine health care services for many more. An analysis by Brenner (p. 1950) shows how the economic consequences brought about by mobility restrictions related to slowing the spread of COVID-19 in the United States are associated with nearly 200 000 combined deaths in the long term as a result of unemployment and bankruptcies.

An article by Shen et al. (p. 2027) considers the interruption to regular health care services brought about by COVID-19. Using data from the Michigan immunization registry, this article shows overall declines in non–COVID-19 vaccination across the life course, including both pediatric and adult vaccinations. It will of course require substantial effort to catch up on vaccinations for all age groups to mitigate the health harms that can come from persons not being vaccinated. The potential long-term health challenges that have emerged from our dealing with COVID-19 do not suggest, of course, that we should not have implemented the efforts needed to limit the spread of a novel, highly contagious pathogen, but they reinforce, with forceful clarity, the costs of such inaction over the life course. That should give us both pause and perspective and should inspire us to balance our actions in the immediate present with an awareness of their health costs in the coming decades.

ATTENDING TO FUTURE HEALTH

It is our job to focus on how we may improve population health over the life course. This requires an unyielding focus on what is difficult to keep in mind—the future—and a near constant reminder to those who are in a position to make policy decisions that will influence the long-term health consequences of our actions today. Articles such as the ones in this issue of AJPH do an invaluable job of building the evidence base that can help to this end.