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2 Connecting Health and the Economy: The Surgeon Generalâs Call to Action To open the workshop, Jerome Adams, 20th Surgeon General of the United States and Vice Admiral of the U.S. Public Health Service Commissioned Corps, delivered a keynote address issuing a call to action to connect health and the economy. The session was moderated by Cathy Baase of the Michigan Health Improvement Alliance. (Highlights of this session are presented in Box 2-1.) BOX 2-1 Highlights from the Presentation by U.S. Surgeon General Jerome Adams* â¢ The United States lags behind comparable countries in a range of health metrics, and health disparities in the nation are increasing. â¢ Addressing upstream determinants of health does not exempt people from personal responsibility, but the choices that people can make are entirely dependent on the choices available to them. â¢ Money that individuals and employers must spend on health care is money that could be spent on other priorities, such as education, infrastructure, wage increases, or individual purchases (which stimulate the economy). â¢ Healthier people are more productive, and healthier communities are more prosperous and safer. â¢ Engaging a broad range of partners to innovate and promote upstream interventions can help communities thrive. Non-traditional partners with community connections can be essential advocates for health in the community. * This list is the rapporteurâs summary of the main points made by Adams and does not reflect any consensus among symposium participants, or endorsement by the National Academies of Sciences, Engineering, and Medicine. HEALTH AND THE ECONOMY In defining his priorities as Surgeon General, Adams said he chose to include community health and economic prosperity because he believes those issues have the potential to influence all aspects of health. âProsperous and economically stable individuals tend to be healthier,â he said. At the same time, individuals and communities that are healthier tend to be more prosperous. Adamsâ signature Call to Action is titledâand will focus onâCommunity Health 5 PREPUBLICATION COPY: UNCORRECTED PROOFS
REORIENTING INVESTMENT PRIORITIES TOWARD HEALTH AND WELL-BEING and Economic Prosperity, including the role of private-sector investment in promoting community health and economic well-being.1 Much of health care, policy, and political debate is focused on optimizing downstream interventions. Adams pointed out, however, that less than 20 percent of health is influenced by health care. Health is influenced primarily by an individualâs environment and behaviors. There is not sufficient investment upstream, he said, in the health and well-being of communities and in activities that could prevent disease and reduce health care costs (e.g., addressing social determinants of health). More value can be obtained from Americaâs health care dollars. Health in the United States is âfar from where it could be,â Adams said, and the nation lags behind comparable countries in a range of health metrics. Within the United States, health disparities are increasing. The goal of a healthier, more prosperous, and equitable America cannot be realized unless the upstream determinants of health are addressed, he said. Those determinants of health can provide people with opportunities to make healthier choices. Social determinants of health include, for example, housing, education, employment, transportation, and connections to oneâs community. These and other social determinants of health âhave a profound impact on a personâs ability to be born healthy and to stay healthy across the life span, to engage in healthy behaviors, and to avoid conditions like heart disease, diabetes, and obesity,â Adams said. Addressing upstream determinants of health does not exempt people from personal responsibility, he continued, but the choices that people can make are entirely dependent on the choices available to them. For example, not all families can choose to send their children outside to play because they may have safety concerns (e.g., traffic, violence). Similarly, many cannot choose to eat fresh fruits and vegetables regularly because grocery stores are less accessible to them than local convenience stores or fast-food restaurants. Placemaking Hospitals and health care providers, businesses and employers, and local governments are beginning to recognize the role of a communityâs environment (i.e., âplaceâ) in driving good health, and the role of good health in driving the economic prosperity of the community, Adams said. As an example, he mentioned the recent search by Amazon for a location for a second corporate headquarters. Ultimately, Amazon chose to split its second headquarters between two sites, one in New York City and one in Crystal City, VA.2 Citing U.S. News and World Reports 2018 healthiest communities rankings,3 Adams suggested that âitâs no coincidenceâ that Crystal City, VA is surrounded by 3 of the top 10 healthiest communities in the country (Falls Church, Loudoun County, and City of Fairfax). While local governments often provide tax incentives to attract businesses, forward-thinking communities are now focused on placemaking. Investing in the health of the community helps to reign in unsustainable health care costs, and Adams added 1 For information on the Surgeon Generalâs Call to Action: Community Health and Prosperity, see https://www.federalregister.gov/documents/2018/09/06/2018-19313/surgeon-generals-call-to-action-community- health-and-prosperity#addresses (accessed February 8, 2019) . 2 The company announced in February 2019 it would rescind plans for its New York City location (see for example https://www.nytimes.com/2019/02/14/nyregion/amazon-hq2-queens.html (accessed October 8, 2019) . 3 Available at https://www.usnews.com/news/healthiest-communities/rankings (accessed February 8, 2019) . 6 PREPUBLICATION COPY: UNCORRECTED PROOFS
INTRODUCTION that health care costs for current and future employees is a significant concern for most employers, including Amazon. Every community can become healthier, Adams said, but special attention is needed to address the challenges facing those most in need, in the most disadvantaged communities. Forging New Partnerships Adamsâs motto as Surgeon General, he said, is âbetter health through better partnerships.â The problems that need to be solved are multifactorial and the solutions are complex. The work of improving community health has many stakeholders, and Adams called for forging new, innovative, and broad-ranging partnerships. Adams spoke about the concept of servant leadership, which he described as âleading by meeting the needs of others, so that their success leads to your success.â He said that, as Surgeon General, he is âcommitted to being a servant leader, to strengthening connections within the health community, and to forging those new partnerships that can help us solve our most pressing health problems.â As an example of reaching out across silos to forge new partnerships, Adams described engaging the National Association of Attorneys General. Although some might believe the law enforcement community wants only to lock up those suffering from substance use disorder, he said, the fact is that prisons and jails are the largest providers of mental health services in the United States. Potential partners for health can be found in law enforcement, academia, the military, faith leaders, and many other sectors. It is important to invite them to the table as stakeholders in community health, he continued, but also to go to their table, listen, and be a servant leader. Many potential partners, even some in the health sector, are not aware of the value of investing in community health and the potential return on investment, Adams said. Health care costs account for nearly one-fifth of the U.S. economy, Adams said. Families, businesses, and government all feel the burden of poor health and its impact on prosperity. Currently there are 6 million unfilled jobs in the United States, and Adams noted that many people who might fill these jobs are not looking for work due to health-related issues. Money spent on health care, whether by an employer (e.g., to provide coverage) or an employee (e.g., for a copay or deductible), is money that could be spent on other priorities, he continued. Money not spent on health care could be spent on education, infrastructure, or wage increases, for example, or even on holiday gifts or other purchases that, in turn, stimulate the economy. Adams suggested that a main reason wages have remained stagnant is because businesses are paying higher health care costs. The outcomes associated with health inequities impact everyone, Adams said. The mission should be to deliver âhealthier children to our schools, healthier workers to employers and businesses, and a healthier population to communities,â he said. The evidence supports the notion that healthier people are more productive, and healthier communities are more prosperous and safer. Adams noted several examples, including the Purpose Built Communities of East Lake, Georgia; the Minneapolis, Minnesota, Blue Zones; and Live Well, San Diego in California. The economy has long been a top issue for voters, regardless of party, demographic, or geography, noted Adams. Although many voters in the most recent election cited health care as 7 PREPUBLICATION COPY: UNCORRECTED PROOFS
REORIENTING INVESTMENT PRIORITIES TOWARD HEALTH AND WELL-BEING their top concern, Adams suggested that these voters were not actually voting on health as an issue, but on the economic aspects of health care (i.e., the high costs of health care are impacting their ability to pay for other needs). Education is needed so that employers, policy makers, and the public understand that the return on investment in health is economic development and prosperity for individuals and the community. Adams said the forthcoming Surgeon Generalâs report will âdemonstrate the link between community health and economic prosperity and provide tools for community investment that deliver health impact.â These tools can be used by health care organizations, businesses, philanthropies, financial institutions, community planners, and other stakeholders to improve community health and foster prosperity. Adams expressed hope that the forthcoming Surgeon Generalâs report on Community Health and Prosperity will end any debate about the association between health and the economy and will inspire action by all stakeholders in health. Moving Forward In closing, Adams reiterated his Surgeon Generalâs Call to Action message to participants, encouraging them to: â¢ Innovate and promote upstream interventions that can help communities thrive and achieve âbetter health through better partnerships.â â¢ Engage a broad range of partners in discussions of public health issues, including faith communities, military, local businesses, law enforcement, and others. These stakeholders have influence at the highest policy levels and at critical touch points for community health. Non-traditional partners who have community connections can be essential advocates for health in the community. â¢ Communicate more effectively that the pathway to prosperous communities starts with healthier communities. Partners in the communities are interested in profits and costs. Focus on how improving health can impact their financial bottom line. â¢ Incorporate health equity into everything because when health inequity exists, âwe all pay the price.â Interventions should benefit and be accessible to all communities, and not just improve the health of those who are already doing well. As an example, Adams said there has been success in driving down opioid prescribing rates, but what is often overlooked is the fact that people with unmanaged pain have started using injection drugs instead. Ignoring inequities âmakes the problem worse for the communities that are most in need.â âWe have the opportunities,â Adams concluded, and he said he was ready to work toward improved overall health opportunities and health outcomes for all. DISCUSSION In the brief discussion that followed, Josh Sharfstein of the Bloomberg School of Public Health at Johns Hopkins University asked about incorporating âa constructive discussion on immigration as part of an overall approach to health and the economy.â He suggested that current and proposed immigration policies can negatively impact health and observed that immigrants often fill the job vacancies that Adams mentioned. Adams responded that better communication is needed to disseminate the message that âthere is a net benefit to making sure there is a 8 PREPUBLICATION COPY: UNCORRECTED PROOFS
INTRODUCTION reasonable immigration system.â A challenge is that one bad story involving an immigrant can taint public perception. John Auerbach of Trust for Americaâs Health observed that, despite significant attention to obesity as a health issue, the latest data show that obesity rates for both children and adults continue to increase. He asked what could be done differently to see improvement. Adams concurred that addressing obesity in the United States is an ongoing challenge. Better communication is needed about the role of a personâs environment in the choices they are able to make, he said, for example, whether they have access to healthy foods, or safe places to be active. Better choices need to be more readily available. There is also a need to create environments that allow people to incorporate being physically active throughout the day, he said, not just when they set aside time to go to the gym. 9 PREPUBLICATION COPY: UNCORRECTED PROOFS