Paula Braveman,
University of California, San Francisco School of Medicine
August 5, 2009
NOTE: The following is in response to a piece on The Huffington Post from RWJF's James Marks titled, "What if Benjamin Franklin Ran the Congressional Budget Office?"
The author, Paula Braveman, MD, MPH, is based at the University of California, San Francisco School of Medicine. She is co-director of research for the Robert Wood Johnson Foundation Commission to Build a Healthier America.
Dr. Marks’ comments strike a personally resonant chord. As a family physician, all my medical training and years in practice centered on a view of patients in the context not only of their families and communities but of their own life courses. “The child is father to the man.” We become who we are as adults and as we age, based to an important extent on who we were as children etc. Caring for multiple generations of some families, I often could see glimmers of what might, at least without intervention, lie decades ahead for a child or young adult, reflected in the health of older members of their families. Investment in the care of the infant, the toddler, the young child, adolescent and even young adult sometimes might yield some measurable short-term returns, but the pay-off on the investment might not be seen until middle-age or even later, when the toll of chronic diseases like adult-onset diabetes, heart disease, and arthritis begins to surface; that toll is ugly and painful for individuals and prohibitively expensive for families and society. If I had used the current criteria of the Congressional Budget Office – considering costs and benefits not more than 10 years out-- I would have withheld much of the care I gave or recommended to children and young adults.
Dr. Marks’ words also resonate with central concerns in another area of my professional life, namely my research on the profound disparities in health we have in the U.S., both by race or ethnic group and by social class (as typically measured by income or education). Disparities in quality medical care are certainly one element that must be addressed to close the avoidable and unfair health gaps in our society. But a huge body of evidence has accumulated by now telling us that medical care is just one piece of the puzzle.
Closing the gaps in health by race and class w ill require effective social policies in the realms of child care, schools, food policy, housing, urban planning and transportation. There is something almost all of these policy realms have in common, besides their enormous potential effects on health: The health effects will likely not be sizable and measurable for decades. Their yield is produced through a multitude of pathways; let me trace just a few. High-quality Early Head Start-type programs will narrow gaps in readiness-to-learn, resulting in smaller gaps in educational attainment reached by young adulthood. Higher educational levels will generally mean greater knowledge of health and healthier behaviors, but also will mean better jobs with higher income. Better jobs will be less hazardous to health and will bring health insurance. Higher incomes make it possible not only to purchase more nutritious food but also to live in healthier housing in healthier neighborhoods – neighborhoods with safe areas to play and exercise, places selling nutritious food, with good role models for healthy behaviors, and with good schools for one’s children, to begin the cycle again with the next generation. Research has shown that vicious cycles can be interrupted; we know how to do that now. A better educated, healthier labor force is more productive; recognizing that, the Business Roundtable, a group comprised of the CEO’s of the U.S.’ major businesses, has called for universal high-quality early childhood development programs based on the long-term implications for business. Adhering to the 10-year limit for considering policy consequences would mean that none of these effects would be considered.
An array of reports and tools lays out these issues and relevant evidence here on website for the Robert Wood Johnson Foundation’s Commission to Build a Healthier America (commissiononhealth.org), for which I have served as Research Director. My colleagues and I on the Commission’s research staff have struggled with this issue of what evidence should be considered in recommending policies, and concluded after a great deal of reflection and discussion that policy must be made on the best available evidence, with due consideration of its limitations. The long-term effects of policies must be considered. We need more investment in longitudinal studies of the health effects of social policies. But we don’t need to wait the decades that must pass before having that evidence in our hands. Thoughtful people can derive very useful guidance from the knowledge to which we have access now, by connecting the dots. The resultant knowledge will be imperfect – but making policies that fail to consider long-term effects is not the solution.
Surely it is time for a reconsideration of the way CBO assesses the costs and benefits of policies with potential relevance to health. In the absence of knowledge of likely long-term implications, there is no counterweight to politics and vested interests. CBO should synthesize and present for consideration the best available knowledge on long- as well as short-term effects on health and other concerns. That knowledge will in most cases come from an array of sources –including but not limited to randomized controlled experiments-- each of which should be weighed for its strength and weaknesses. Ethical concerns –such as the consequences for racial and socioeconomic disparities in health-- need to be part of the systematic process as well. What is at stake? Not only our values, but, as both the Business Roundtable and the World Health Organization have concluded, a healthier, more prosperous America for all of us.