Regardless of which candidate or party wins the coming presidential election, American policymakers face a series of ongoing epidemics, with deep and unequal effect. In a in the New England Journal of Medicine, Marcella Alsan, the Angelopoulos Professor of Public Policy at vlog, talks about the public health issues, and policy choices, facing the next administration. We asked her about these epidemics, which impact the United States more severely than peer countries in the Organization for Economic Cooperation and Development (OECD), and the way to approach policy solutions.
Q: Your New England Journal of Medicine article focused on ongoing epidemics. What are they and why did you pick them?
These epidemics—firearm violence, opioid overdose deaths, obesity, maternal mortality, and mental health crises—are more pronounced in the United States compared to other high-income OECD countries and their burden is not distributed evenly. This suggests that policy can be used to manage them or prevent them altogether. The relatively high rates are also sometimes driven by a disproportionate burden concentrated among low-income or minoritized individuals.
For instance, firearm-related mortality rate is 12 per 100,000 people in the U.S. versus 0.9 per 100,000 in high-income OECD countries. And within the U.S., firearm-related mortality disproportionately affects Black Americans, with a rate of 33.2 per 100,000, compared to 12.2 per 100,000 among white Americans.
Similarly, in the United States opioid use disorder deaths per 100,000 stand at 17, while the average of the OECD countries is 2. Within the U.S., this issue is concentrated among individuals with lower educational attainment. Those without a high school diploma face mortality rates over 50 per 100,000, compared to just 4.9 per 100,000 for those with a college degree. Maternal mortality is another critical issue. While the maternal mortality rate per 100,000 live births is 21 in the U.S., it is only 6 in OECD countries. Black women in the U.S. experience maternal mortality rates of 69.9 deaths per 100,000 live births, which is more than 2.5 times the rate for white women. These stark differences highlight structural inequities within the healthcare system that are unique to America. These epidemics were chosen because they are reflective of broader societal issues, including access to healthcare, socioeconomic disparities, and the influence of structural racism.
“Addressing these issues requires viewing health disparities through the lens of inequity, acknowledging that certain populations face far greater barriers to achieving good health.”
Q: You write that “the burden of disease is not distributed equally throughout the country.” Why are these health crises issues of inequity?
Taking a step back, policy is an attempt by local, state, or federal authorities to achieve some social objective. Whether or not one views differences in outcomes across groups as an inequity depends on how one interprets the driving factors behind those differences. However, for health outcomes, it’s particularly egregious to think about premature morbidity and mortality that is concentrated among the poor, less educated, and/or minority communities as not requiring some remediation.
For instance, maternal mortality and firearm-related deaths disproportionately impact Black and Native American communities. Black women are more than twice as likely to die from childbirth complications compared to white women, often due to systemic barriers to quality care, implicit biases in healthcare settings, and reduced access to prenatal services.
Firearm violence, the leading cause of death among children in the U.S., is heavily concentrated in marginalized racial and ethnic communities, particularly among Black and Native American populations. Opioid overdose deaths are similarly skewed, disproportionately affecting lower-income, less-educated individuals.
Childhood obesity also shows significant inequalities. Obesity rates are significantly higher among children from low-income families compared to wealthier ones. Among children aged 10-17, those living in households with incomes below the federal poverty level (FPL) have an obesity prevalence of 24.3%, compared to just 9% in households with incomes at 400% or more of the FPL. This disparity arises from limited access to healthy food options, fewer opportunities for physical activity, and unhealthy food environments in lower-income areas.
These inequities are not only driven by gaps in healthcare access but also by broader societal inequalities, such as economic insecurity, residential segregation, and reduced access to preventive services. Addressing these issues requires viewing health disparities through the lens of inequity, acknowledging that certain populations face far greater barriers to achieving good health.
Q: These are enormously complex problems. How do you approach policy solutions?
To start, there needs to be a shared understanding that this unevenness in health outcomes is indeed a problem—and that the government is at least partially responsible for solving it. Many of these issues require policies that go beyond the biomedical sphere typically associated with healthcare. For example, addressing obesity in lower-income communities is not just about GLP-1 inhibitors, a type of medication that helps manage blood-sugar levels. It also involves improving affordable healthy foods through programs like SNAP and free meals, investing in safe public spaces for physical activity, and ensuring that communities have the resources to support healthier lifestyles (which might include “choice architecture” at grocery stores and taxes on processed foods). Similarly, tackling substance use disorders requires not just treatment, but also anticipating and addressing economic insecurity that leads to structural unemployment.
The solutions demand a whole-of-government approach, where every policy—whether in housing, labor, or education—must consider its impact on health, especially for those groups who are objectively suffering the most as indicated by their lagging health outcomes. It's about creating a system where every individual, regardless of background, has the opportunity to achieve good health—that’s what health equity really means. To achieve that requires a multi-faceted approach. It is tempting to try to fix a health issue with a health solution. However, such myopic quick-fix policy solutions often lead to unintended consequences and merely scratch the surface of these complex issues. Just as a doctor must thoroughly assess a patient's overall health and lifestyle before making a treatment plan, policymakers must take a holistic view of the society they serve to craft effective, lasting solutions to health inequities.
—
Banner image: Emergency medical technicians and paramedics with the Los Angeles Fire Department get ready to take a man they just revived from a drug overdose to the hospital.
Photography by Genaro Molina.