NewPublicHealth Q&A: Marthe Gold
For the Public’s Health: Revitalizing Law and Policy to Meet New Challenges is a new report focused on public policy and its ability to transform health in the United States. The report is the second of three reports on public health policy and law, measurement and funding, produced by the Institute of Medicine (IOM) at the request of the Robert Wood Johnson Foundation and prepared by the IOM Committee on Public Health Strategies to Improve Health.
In the most recent report, the committee examined the legal and regulatory authority for public health activities, identified past efforts to develop model public health legislation, and described the implications of the changing social and policy context for public health laws and regulations. The report found that much of existing public health law was enacted when communicable rather than chronic diseases were the primary population health threats, and therefore recommended that public health law now must be reviewed and revised. The report also recommends a “health in all policies” approach. This is an emerging strategy that recognizes that even laws and policies that don’t specifically address health issues – from determining new transportation routes to setting agricultural subsidies – can have a profound impact on the health of all Americans. The strategy relies on both government and the private sector to evaluate the health effects and costs of all major legislation and policies.
NewPublicHealth spoke with Marthe Gold, M.D., M.P.H., chair of the report committee. Dr. Gold is the Arthur C. Logan Professor and Chair of Community Health and Social Medicine at the Sophie Davis School of Biomedical Education at the City College of New York.
NewPublicHealth: What was the charge of the IOM Committee on Public Health Strategies?
Dr. Gold: The Robert Wood Johnson Foundation asked the IOM to convene a committee to consider three major inter-related topics in public health: measurement, law and funding. The idea was to try to strengthen the public health infrastructure for the United States. So the committee was asked to issue three reports on these topics with the idea of containing actionable recommendations for public health agencies and others who have roles in U.S. population health.
NPH: What is the makeup of the committee?
Dr. Gold: The committee has eighteen members and they come from academia, from private industry, from the medical care delivery system, and from public health practice at state and local levels. There’s expertise within the committee in law, finance, measurements, evidence-based medicine, and quality and performance improvement.
NPH: Is there diversity in their political views?
Dr. Gold: I think there were certain areas where we knocked heads coming to consensus, and there was a wide spectrum of political beliefs about the role of government and how active the government can be in working to promote health. I think the committee… looked to bring people in who exhibited different political perspectives.
NPH: From your perspective, was that an important thing to do because it allowed you to discuss the report and the actions that the report was recommending in a somewhat similar way to how it might be discussed once the report was released?
Dr. Gold: I think we were very mindful of the idea that we are in a somewhat polarized political environment, and in order for the report to be salient across many different perspectives and have actionable recommendations, we needed to find a way through that had resonance for all readers.
NPH: What was the specific goal of the most recently released report?
Dr. Gold: The committee was asked to review how statutes and regulations prevent injury and disease. The committee was to systematically discuss legal and regulatory authority and describe the implications of changing social policy context for public health laws and regulations. The committee was also asked to note past efforts to develop model public health legislation, which are public health laws that are publicly recommended as exemplary. Examples of model public health legislation include Good Samaritan laws during public health emergencies and policies around closing schools during communicable disease outbreaks.
I think the committee extended its task a little bit, to also focus on policy in addition to law. Policy in the governmental framework as well as in the private sector can have a profound impact on the health of populations. So you can have a large employer, for example, who makes policy that has to do with keeping workers safer or healthier or having particular foods available in the cafeteria – all of those things are policy, and the committee didn’t want to say, ‘it’s the law only.’ We said let’s also consider what policy can do.
As far as summarizing what’s in the report, it’s not limited to a single message, but I think many of the committee members would say that the thing that was newest in terms of the fullness of its discussion in a national context was the notion of the call to consider the health effects of all major legislation and policies before enacting them, and evaluating them subsequently. So this is paraphrased as the “health in all policies” movement, which has certainly gained steam in other industrialized countries and is beginning to become well known at the state level in certain parts of the United States. Asking all sectors and all players to think when they are about to develop legislation or enact policy – to consider both the positive and the negative effects, and the populations affected – is a key message of the report.
NPH: The report recommends a review of all laws that pertain to public health. Where do you start?
Dr. Gold: Public health agencies at the state level, through their legal counsel, need to first compare the laws that exist in their state to model laws to see where they lack authority or where their authority is in need of augmentation or clarification. And once that process has occurred within the public health department, they need to work with legislative liaisons to propose specific changes that are needed and articulate the clear rationales for those changes so that they can get the support they need from executive and legislative branches.
NPH: What do you think needs to happen for the recommendations to be implemented?
Dr. Gold: There needs to be political will and there needs to be necessary resources to take advantage of what law and policy can do to help people be healthy. So I think the committee is hopeful that they have created a succinct document where they make arguments that are persuasive and will help build political will. Many of the things that are recommended can be done without the addition of resources immediately, such as making sure health departments familiarize themselves with the toolbox of public health legal and policy interventions at their disposal. It’s really about trying to understand the powers that state and local authorities have – making sure that they are aligned with what is the best way forward to enhance the health of the population. The argument that needs to be made is that law and policy have the ability to create infrastructure that will create health and save the United States’ medical care dollars – and there is support for that argument in this report.
NPH: What is a key sticking point in moving the report forward, do you think?
Dr. Gold: We’re in a very challenging economic climate. And there have been these large lay-offs in health departments, none of which have ever been well funded. So there are significant limitations in capacity and important skill sets that are in short supply. But the public health community really needs to successfully mount the case to legislators that investments that limit disease and injury are not only going to improve the health of the nation and create conditions for children to learn better, for communities to be more vital, and for a more productive workforce to exist – but that interventions at the population level are more efficient and more cost-effective than those done at the individual, clinical level. So it is the economic argument in these times that I think is going to be important. For example, if as a nation we had a way to limit salt intake on a population basis we’d decrease the level of hypertension and we’d avoid large numbers of heart attacks and strokes, which all have an enormous burden on the quality of life and the economics of people everywhere.
NPH: Public health accreditation, which will launch in the fall, is voluntary. Why does the report recommend mandatory accreditation?
Dr. Gold: The Public Health Accreditation Board is mindful of the fact that this is more of a start-up enterprise and it’s going to continue to evaluate the accreditation standards that are currently required. So I think they cast themselves in a voluntary framework. I think the committee was persuaded over the time span that we’ve recommended (which is just shy of ten years) that the accreditation process will gain strength, relevance, and steam. And what the committee was after was to provide an infrastructure where communities and regions really understood the capacity to service its core public health functions, and to make sure that capacity was available and accessible to all Americans. So it’s a vote of confidence in the accreditation process and it’s also taking note of the fact that in many other sectors accreditation is mandatory. We’re taking our cues from the idea that there needs to be standards that people should adhere to.
NPH: Do you think legislators are going to support the idea of “health in all policies?”
Dr. Gold: I think they will if we can de-link the idea from this being a political process, which of course is a challenge. The committee makes a point that people from all political perspectives are looking to support the nation’s ability to provide good health, to provide opportunity for all, and to create a vigorous economy that fuels opportunities – it’s just that people from different political perspectives come at it from different angles. What the committee is asking is that when the political process pushes forward a particular legislation or policy that the health implications of those practices are scrutinized through the lens of the impact it’s going to have on health. So it’s not really a political ideology – it’s using the science that you know to decide on the better investment.
In the social world, understanding education is really the strongest predictor of long-term health and longevity. A political process needs to review and evaluate educational policy through the lens of what keeps children in school and what fosters their success because we know that if you finish college, as opposed to not completing high school, you probably have a seven-year differential in expected longevity. Different political sensibilities will argue as to the best way to deliver education so that it accomplishes the objectives of keeping students in school and keeping them successful. They need to then be evaluating whatever those policies are to see whether the outcomes are doing what they are supposed to be doing and whether they are linked with increasing the health of young Americans. So I think that “health in all policies” doesn’t have to be inherently political – it just needs to be regarded, studied, or developed as policies get implemented. And the other thing I would say about “health in all policies” is that they’re not always legislatively determined. That goes back to what I was saying about how the committee took the view that some of the most important kinds of population-based changes are policy ones that happen both privately and publicly.