Is the Goal of “The Healthiest Nation” Attainable or Desirable?

For several years, the American Public Health Association (APHA) has had its sights set on the laudable and lofty goal of creating the healthiest nation in one generation. Since the announcement of the theme “Healthiest Nation 2030” for the 2015 National Public Health Week, this theme has been echoed in various forms and has served as a “clarion call to action” by APHA.¹ This focused attention to the nation’s health has rightly generated many activities in several sectors in the nation and has identified and directed actions toward many important factors affecting health and health equity, such as racism, equal access to health care, and social determinants of health, among others.

At face value, the term “healthiest nation” may seem self-defining, but, in various publications, different definitions have been indirectly alluded to, such as making “the next United States generation the world’s healthiest,”^1(p777) or making the United States the “healthiest that we can be,”^2(pS219) or stating that “the United States has the potential to become the healthiest nation in a healthier world.”^3(p1) Healthiest nation was also introduced as “an aspirational goal . . . that requires a culture change engaging all aspects of our society.”^1(p777) Therefore, variation in how healthiest nation is interpreted and understood is not trivial, because, to a large extent, the definitions set the goals, which, in turn, set the attitudes, strategies, and action steps toward achieving the goals. Moreover, the definition of healthiest nation also defines whether the goal is attainable, on the one hand, and desirable, on the other. In broad terms, healthiest nation can be defined in three ways, each of which should be examined in terms of its attainability and desirability.

THE HEALTHIEST IN THE WORLD

One definition for healthiest nation alluded to in various fora is “healthiest in the world.”^1,3 Much has been written and said about the poor health ranking of the United States compared with other developed nations.^4–6 Given the many social, economic, and political factors that have contributed to this ranking for many decades, many of which continue to operate unabated, one can argue that this goal is unlikely to be attainable—that the United States can become the healthiest nation in the world by 2030, or even in one generation from now, as the goal has been variously promoted. However, regardless of whether this goal is attainable or not, we must also consider the implication and, thus, the desirability of such a goal. By definition, striving to become the healthiest nation in the world can indirectly promote the concepts of otherness and inequity. To strive to be the best in the world means striving to be better than others and leaving others behind—a goal that is not morally desirable or defensible. In any such race, there will only be one “winner” and many “losers,” no matter how well everyone does.

Furthermore, striving to be the healthiest nation in the world is in many ways self-defeating. We have learned many lessons from the pandemic, but, if nothing else, we have learned that, especially when it comes to health in all its dimensions, no nation is an island. The pandemic has made it clear that nations and populations are more interdependent than ever for their health. Even before the pandemic, economic factors, trade, international travel, and migration made any nation’s health dependent on health across the globe. The pandemic made that even clearer—as long as there are countries with substantial portions of their populations unvaccinated, there is fertile ground for new variants, or other infections, to emerge, putting all nations in peril. Therefore, no nation is safe or capable of winning the health race without all other nations having adequate levels of health—a goal that requires not a race as its core concept, but mutual international and intranational cooperation and collaboration.

Similarly, this definition can be self-defeating in another way—by creating a false sense of achievement and complacency. Being the healthiest among a group does not necessarily mean being healthy. An example from County Health Rankings may help illustrate this. An examination of states shows that in the state of Arkansas, for example, among its 75 counties, Benton County has consistently ranked at the top since 2010, scoring as the “healthiest” in the aggregate measures for both health outcomes and health factors, and as number 1 for both length and quality of life.⁷ However, among 34 “peer” counties across the United States (as designated by County Health Rankings based on key demographic, social, and economic indicators), Benton County scores worse than 11 counties for premature deaths, 27 for poor or fair health, 26 for poor physical health, 22 for poor mental health, 6 for low birth weight, 22 for food environment, 20 for uninsured rate, 21 for children in poverty, 19 for reported violent crime rates, and 27 for air pollution, to name a few.⁷ Being the healthiest among a group does not necessarily mean being healthy.

THE HEALTHIEST IT CAN BE

A second way in which heathiest nation can be interpreted is the “healthiest it can be.”² This definition as a goal is desirable but arguably unattainable. Health is a continuum, with no currently definable or measurable endpoint, based on our current understanding. Becoming the healthiest nation we can be implies knowing the limits of health and, more importantly, how to get there. There are many dimensions to health, some of which are poorly studied or understood. We do not yet know or understand all the threats to health—natural or manmade. If we define health not only in physical terms but also in terms of mental, psychological, emotional, and spiritual factors, not only do we not know the limits of health, but we also certainly do not know how all these factors interact to produce ultimate health. Our understanding of such a state of health is changing continuously with new scientific developments. It is, therefore, not possible to be the healthiest we can be, because it is a currently undefinable ideal.

An alternative interpretation of this second definition might be the healthiest we can be “under the current circumstances.” But that is a moving target, because that is, in fact, where we are at any given time—our current health status is the product of our current circumstances. These circumstances encompass our scientific knowledge, our social institutions and infrastructures, and our political will—that is, our current health status is the result of a combination of not only what we know but also how we have chosen, or been forced, to apply that knowledge to the operation of our overall health care and public health systems in all their facets. And the result of all that is the level of health we currently have. It is only by changing these current, mostly social and political, circumstances that we can become healthier than we are now.

THE HEALTHIEST IT HAS EVER BEEN

The term healthiest nation can be defined in yet a third way that is both attainable and desirable: the “healthiest it has ever been.” This definition recognizes the fact that, no matter how healthy we have ever been as a nation, we can always be healthier. There is no limit to that. We can always go a step further, little by little, day by day. And that is potentially attainable.

This definition is also desirable. With this definition, our only “competition” is ourselves, and that means that every nation can be the healthiest nation and continue to strive for better. It puts every nation on its own desirable trajectory of continuous health improvement without having to leave other nations behind to achieve it. It also embodies the concept of continuous health maintenance and guarding against losing ground. Another benefit of this definition as a goal is that aid, assistance, and collaborations with other nations need not be at the expense of jeopardizing our own standing. We can all help each other on the path to health improvement and still maintain our own healthiest status, no matter how healthy other nations become as a result.

However, the desirability of this definition comes with a caveat. Even under this definition, the title of healthiest nation can hide significant levels of disparity within a nation. It is not enough for any nation to be able to say it is the healthiest it has ever been if all segments of the population within the nation cannot say the same thing. That is, it is not enough for average national health indicators to improve if that improvement is not experienced by all segments of society. This conceptualization requires us to think and plan differently about becoming the healthiest nation. Instead of trying to raise the national average—which statistically can be achieved by raising even higher the health of only those already doing the best, or raising their levels more than those at the lower end of the scale—it asks us to pay particular and focused attention to those at the bottom, and to raise their health levels at an even higher rate to close any gaps. In fact, it is likely that in many cases the national average can be raised even faster and more significantly by bringing up the lowest levels first and faster. This approach to the definition, then, requires us to not leave anyone behind, or increase the gap, in the quest to be the healthiest nation we have ever been.

CONCLUSIONS

Even with the attainable and desirable definition of the “healthiest we have ever been,” we have, unfortunately, failed over the past few years. From 2019 to 2021, life expectancy at birth in the United States had its biggest two-year decline since 1921–1923, bringing us to 76.1 years, the lowest level since 1996.⁸ The largest contributors to this decline were COVID-19; increases in deaths from accidents, suicides, and unintentional injuries, including drug overdose deaths; and chronic diseases, all of which have shown disparities along gender, racial, and ethnic lines. This does not bode well for attaining our healthiest nation goal, regardless of what definition we choose to use.

This setback notwithstanding, as a nation, we have made great strides. The public health community can be proud of important campaigns and programs that have led to major gains in health and life expectancy in the United States since the latter part of the 19th century. These campaigns have spanned several decades in the areas of infectious diseases, sanitation, water quality, vaccines and immunizations, tobacco prevention and cessation, trauma systems, and maternal and child health, among others. Initiatives like the decades-long Department of Health and Human Services’ Healthy People campaign, and the more recent APHA’s Healthiest Nation 2030—the focus of this editorial—have impelled us to go further as a nation. These campaigns, and many others, are now calling on us to pay more attention to health equity, and that requires us to think more deliberately and inclusively about how we conceptualize being healthy and how we strive to become the healthiest nation in a way that is both attainable and desirable.