The need to combine social and health policy

First in an occasional series giving advice to the new president.

SINCE THIS is, by all accounts, a "defining moment" in American history, let's redefine the way we think about health. Over the past decade, a rich vein of research has detailed the links between large social forces - from income and discrimination to education and neighborhood safety - and a community's physical and mental well-being.

Last summer, a pair of fascinating reports - overlooked in the US press - drew on this perspective to suggest a blueprint for the next administration's health agenda. Both reports stepped back from our conventional explanations of health - "individual lifestyle" and "biomedical miracle" - to analyze the structural factors behind disease and suffering in our society.

"The Measure of America," published by the Social Science Research Council, an independent research organization based in New York, examined US health through a novel lens: the human development model that the United Nations has applied around the world - but, until now, never to the world's richest and most powerful country.

Underscoring how far we lag in our promise, the report documented how the roughly $5.2 billion we spend every day on healthcare yields a pitiable return on investment. For example, US life expectancy ranks below that of Chile, Costa Rica, and nearly every European and Nordic country. The US infant mortality rate is on par with that of Croatia, Cuba, Estonia, and Poland. Within the United States, stark health inequities persist along socioeconomic and racial/ethnic lines.

What's behind these dismal facts? Not just sedentary habits or calorie-laden diets, although obesity is a major factor in America's relatively faltering position. Rather, it's how public- and private-sector priorities shape health. As the other groundbreaking document - the World Health Organization's final report from the Commission on Social Determinants of Health, "Closing the gap in a generation" - explains: "The unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics."

And so, the defining moment. If President-elect Barack Obama wants to live up to his ambitious vision, then he must combine social and health policy. First and foremost, push for universal healthcare. "Just like smoking and diabetes, lack of health insurance is an early death sentence," said Sarah Burd-Sharps, a former UN administrator and co-author of "The Measure of America." Every rich nation in the world except ours has figured out how to provide health coverage to virtually every citizen - and at far lower cost per capita.

Next, as do most European and Scandinavian countries, weigh the health consequences of policies in taxation, business development, transportation, housing, agriculture, and so on. Make improving population health and reducing health inequities a criterion for all government initiatives.

Finally, don't use the recession as an excuse not to act. Throughout American history, our bodies have responded well to strong doses of social "medicine." The Depression of the 1930s saw Social Security and collective bargaining - both of which vastly improved health. During the late 20th century, motor vehicle laws, including mandatory seat belts, child seats and lower speed limits, likely saved more lives than anything high-tech medicine offered. According to a 2008 Harvard University study, even the contours of America's entrenched health inequities can change with visionary policy. From 1966 to 1980 - in the wake of the War on Poverty, the US Civil Rights Act, and the establishment of Medicare, Medicaid, community health centers, and the Environmental Protection Agency - US socioeconomic and racial/ethnic disparities in premature mortality and infant death shrank; after 1980, when Republican politics hollowed out the public sector, disparities widened.

In other words, think big. As Dr. Georges Benjamin, executive director of the American Public Health Association, told me during the group's annual meeting last month: "I would love Barack Obama to declare that he wants America to be the healthiest nation in the world - in a generation. Americans need to rally around the idea of grappling not only with healthcare, but with health."

Madeline Drexler, a former medical columnist for the Boston Globe Magazine, is a Boston-based journalist and author.