During summer, much of our school community spent time away from our campus—vacationing with family, working abroad, or simply adventuring. With the new academic year now underway, we have returned to SPH, to once more call Massachusetts home for the coming semester. With our deep roots in the state, it is worth taking a moment, as we renew our connection to the Commonwealth, to pause and consider health here.
Massachusetts is a state that is, in many ways, ahead of the national curve when it comes to health. It also has its own unique health challenges. What, then, are some policy efforts that can indeed achieve better population health in Massachusetts? I solicited answers to the question from the School’s Governing Council members, and added to the list a few of my own thoughts. Here I summarize six such ideas that rise to the top, in no particular order. The intent is to highlight ideas that are indeed doable, and that can yield benefits to the health of populations in both the short- and long-term.
- Create universal free pre-kindergarten starting at age 3. There is strong evidence to show that early intervention and childhood education has lasting impacts on health and economic outcomes. The period from birth to age 5 is critical in terms of cognitive stimulation affecting future development. In turn, early cognitive development is associated with a broad range of long-term health outcomes. High-quality preschool programs advance school readiness and can prepare children for achievement in school, vaulting them to better educational and job performance in the future. Not surprisingly, the potential benefits of early childhood achievement programs may be more pronounced for economically disadvantaged children, narrowing the “readiness gap” and later achievement gaps. A comprehensive RAND report summarized effects of various early education programs, including significant improvements in achievement test scores, positive behaviors, child abuse reduction, and emergency room visits—all high-yield, short-term benefits. Abundant literature suggests long-term benefits. For example, a longitudinal study found that participation in Head Startwas associated with increased probability of graduating high school and attending college among white students, and decreased probability of being convicted of a crime among black students. There was even a spillover effect to participants’ younger siblings; the Abecedarian Project, a randomized controlled trial of early childhood education for children from low-income families, found that children in the treatment group were more likely to attend a four-year college and have skilled employment; the Perry Preschool Study found that a high-quality preschool program was significantly associated with high school graduation, higher earnings, fewer arrests, and less time in prison. Outcomes of early education may even span generations to affect the social mobility of children and grandchildren of participants. Such programs can have substantial spillover economic effects, including lower costs for special education, increased labor force participation and earnings in adulthood, increased tax revenue, lower costs to the child welfare system, lower costs for the criminal justice system, lower medical costs, and economic growth.
- Increase alcohol taxation in the state. There is no question that alcohol taxation is linked to less alcohol consumption and that said taxation will, in turn, reduce substantial morbidity and mortality in the state. The health consequence of unhealthy alcohol use are abundantly clear, including cardiovascular disease, injury, liver damage, mortality, violence, and other health outcomes. Just to cite one example, Ziming Xuan from our community health sciences department recently led a studythat found a 1 percent increase in alcohol prices was associated with a 1.4 percent decrease in the prevalence of adults who binge drink. Several economic studies have found that increasing alcohol prices can lower drinking and driving, alcohol-related injury and death, and alcohol-related violence and crime. Forward-looking alcohol taxation can both decrease alcohol consumption and channel tax revenue into health promoting opportunities such as those discussed here.
- Establish broader substance abuse scholarship, prevention, and training opportunities. Statewide centers of excellence for alcohol and other drug use on health campuses can train leaders in the field, contribute to knowledge in this area, and enrich the state’s workforce of health personnel who are equipped to deal with substance use prevention. Evidence of the consequences of substance use is overwhelming. To cite just one set of examples, unintentional overdose has been the leading cause of injury deaths among adults. Overdose deaths have also been increasing over the past few decades; from 1999 to 2008, hospitalization rates for overdoses increased by 55 percent, costing about $737 million in 2008. Alcohol and drug use are also associated with increased crime as well as the negative health effects noted above. There is abundant evidence for the success of drug and alcohol prevention programs and a loud chorus of voices calling for the decriminalization of drug-related offences and a focus on substance use as a public health problem. Most recently, the sheriff of Gloucester made headlines by shifting his focus from arresting heroin users to helping them link with care. These approaches hold tremendous promise, and the state can be a leader in scholarship, prevention, and treatment in the area, tipping the national balance on the issue.
- Lead the nation in vaccination rates. Vaccination is one of the sentinel triumphs of public health. A historical analysis in JAMA found a 92 percent decline in cases and 99 percent decline in deaths due to diphtheria, mumps, pertussis, and tetanus because of vaccination in the US. More recently, hepatitis A, acute hepatitis B, Hib, and varicella cases and deaths declined more than 80 percent. An economic analysis estimated that the routine US child immunization schedule saved $9.9 billion in direct cost and $43.3 billion in societal costs for a birth cohort in 2001. Vaccination is considered a target area of the CDC’s Strategy for the 21st Century of Preventing Emerging Infectious Diseases. However, vaccination rates nationally have plateaued, or in some case have dropped over the past decade, with alarming consequences. An outbreak of measles in late 2014 in California was an example of the dangers of refusing vaccination; there were more cases in 2014 than the total number of cases in nine of the last 14 years, attributed heavily to growing fear of adverse effects of vaccinating children, which have been proven. This represents a “low-hanging fruit” opportunity for Massachusetts to lead nationally by example, by setting the highest vaccine participation standards and by minimizing vaccine refusal rates. Legislation like that passed in California, limiting reasons for vaccination exemptions, pave the way. A comprehensive statewide effort, combining legislative efforts and concerted resources invested in maximizing state-level vaccination rates, can provide best-practice opportunities to reverse national trends and boost hard-won decreases in preventable infectious diseases.
- Change the restrictions on definitions of homelessness. Although overall homelessness has decreased in the US, the rate in Massachusetts has increased faster than in any other state. Homelessness in and of itself is an adverse condition that traps many in a cycle of poverty. It is also associated with increased risk of a range of health problems, including drug use, poor nutrition, asthma, HIV transmission, and mental health problems, especially among youth. Many factors contribute to homelessness, many of them multifactorial and complex. However, at a simple level, restrictive definitions of homelessness reduce the number of individuals eligible for affordable housing and increase the number of people who are homeless. Restrictive definitions of homelessness that do not count people as homeless if they are living doubled up with relatives or friends or in motels, for example, mean that only 1 in 10 homeless children in the US are eligible for federal housing assistance.
- Establish mental health prevention and intervention programs for military members and Massachusetts veterans. Since September 11, 2001, almost three million service members have been deployed to Iraq and Afghanistan. A much smaller proportion of soldiers have died in these recent conflicts compared to previous wars, but this change results in many more veterans returning home with mental and physical health problems following combat. As many as half of returning veterans are faced with conditions including depression, suicidality, post-traumatic stress disorder, impairments in functioning, and traumatic brain injury. Although care of veterans typically falls to the Department of Defense and the Department of Veteran’s Affairs, a study of veterans with psychiatric diagnoses found ample evidence that this care falls short, particularly for reserve members. For example, one study showed an average of seven and a half years between an initial mental health treatment assessment and initiation of minimally adequate care, highlighting a major strain on the Veteran’s Affairs treatment system to provide services. Massachusetts has an opportunity to be the standard-bearer nationwide, to introduce programs that tackle veterans’ health as a core responsibility of a system that has benefitted from the veteran’s service, giving back to many who have given substantially of themselves.
In closing, a note of optimism. A previous version of this note, from 2015, contained some additional suggestions, including raising the minimum tobacco sales age to 21, banning tanning beds, and clearing criminal records for individuals charged with nonviolent drug offenses.
Happily, we have since made progress in each of these areas, which is why they are not included here. The state has indeed raised the minimum tobacco sales age to 21. It has also banned minors from using tannings beds, and opened the door to expunging juvenile criminal records and records arising from marijuana use.
This is all to the good, and will do much to improve health. Raising the tobacco sales age is a potent tool for lowering smoking rates, banning tanning beds will help prevent cancer, and clearing criminal records for nonviolent drug offenses will help reduce the mass incarceration that has done so much to undermine health (see my prior writing on this). Each of these areas represents progress, a step towards making this state as healthy as it can be, setting an example for how the rest of the country might do the same. We are not fully there—but we are headed in the right direction.
I hope everyone has a terrific week. Until next week.