The New England Journal of Medicine released a study Tuesday estimating that at least 4,645 people died in Puerto Rico in the wake of Hurricane Maria. This death toll is more than 70 times the official government estimate of 64 people and is likely still only a fraction of the storm’s full human cost.
When Maria struck Puerto Rico nearly a year ago, it struck an island that had already long been in distress. Decades of political marginalization, an out-of-date power grid, crumbling roads and a moribund economy amplified the storm’s destructive power and have hindered recovery in the region. And it’s because of these deprivations that the hurricane’s long-term health effects ― the sickness and death caused by post-traumatic stress disorder, disrupted medical care, contaminated flood waters, mold and other hazards ― continue to unfold.
These challenges were not inevitable; rather, they reflect years of political disinvestment in the social, economic and environmental conditions that, taken together, are often the difference between resilience and ruin when disaster strikes.
These conditions also shape health when the weather is fair: If they are neglected or undermined, they increase the threat of disease. If they are nurtured and improved, they enable everyone to live a healthy life.
Improving the conditions that shape civilian health is a crucial function of politics. When most people think about politics and health, they tend to think only of health care. Yet health is influenced by the full range of political activity, not just the back and forth of the health care debate. We are healthy because we have clean air and water, because we live in a safe neighborhood, and because we make enough money to afford resources like nutritious food and quality education. Health care provides us with medicines when we are sick, yes, but it doesn’t impact the larger factors that help us stay well.
Every death on the island is an indictment of years of political failure to foster health by improving conditions in the region.
These larger factors depend on the policies and institutions that emerge from politics. Our air and water are clean because of the Environmental Protection Agency. Our neighborhoods are safe when state and federal government invest in them. Our economy is fair when regulation prevents the markets from becoming destructive of the public good.
There are, of course, some who argue these policies and regulations are examples of federal “overreach” and infringe on individual liberty. Conservative advocate Grover Norquist captured this philosophy well when he said, “My goal is to reduce the size of government by half over 25 years … and eventually get it small enough that if you wanted, you could drown it in the tub.” This ethos has been embraced by the Trump administration, which, in 2017, released a so-called “skinny budget” characterized by deep cuts to the administrative structures that safeguard health in the United States.
We don’t need to speculate about the effect that disinvesting from these structures will have on health. We know that it will undermine it because we have tried implementing this policy vision before. This was the core political project of Ronald Reagan, who said in his inaugural address, “government is the problem.” He tried to solve this “problem” by shrinking non-military facets of the U.S. government ― if not to tub-size, then at least until it was small enough to fit inside the bathroom — through measures like deregulating the economy, rolling back worker protections and attempting to weaken the EPA.
In the decades since the Reagan Revolution, the consequences of these policies have become clear. In the 1980s, U.S. life expectancy was higher than that of many other high-income countries. Today, our lives are shorter than nearly all of our peer countries. We are also sicker than many of these nations, suffering from higher mortality rates from non-communicable diseases such as cancer and heart disease. This is despite our investment in health care, which is far higher than that of any other country. Yet our health remains mediocre because political ideology has led us to spend too little on improving the broader conditions that shape health.
Reagan’s legacy is a reminder that politics lies at the heart of health. Another reminder of this is the legacy that Reagan was trying to erase, that of the Great Society. This ambitious federal initiative, led in the 1960s by President Lyndon Johnson, encompassed a host of domestic legislation around issues like civil rights, housing, education and the environment. Building on the reforms of the New Deal, the Great Society was an across-the-board effort to address, at the political level, the full range of conditions that shape health. While some may call this “overreach,” they cannot deny that health in the U.S. was far more robust in the years before these reforms came under sustained political attack than they are now. The Great Society was not perfect, but it remains an example of the good that politics can do when it mobilizes to address the foundational causes of health.
Health is influenced by the full range of political activity, not just the back and forth of the health care debate.
I have not mentioned the Affordable Care Act. The ACA is a good example of government working to safeguard health, but it nevertheless falls into the narrow category of health care, leaving unaddressed the underlying conditions that shape health. While the ACA is important, and repealing it would undermine health for millions, I would argue that the Obama administration’s most important health decision was actually its leadership on climate change. Climate change affects the health of everyone on the planet, fueling the threat of hurricanes and floods, the hazard of extreme heat, and the perilous forced migration caused by natural disasters. Given these dangers, the Trump administration’s most consequential health decision may, in the long run, be its choice to withdraw from the Paris climate accords.
Addressing big challenges like climate change is the job of politicians. Like climate change, the forces that shape health are large, ubiquitous and cannot be influenced by individuals alone. It is only by working collectively, in the political arena, that we can improve society at the structural level to build a healthier world. Politics has the power to create this world, but it can also take us backward, reversing the health gains we have made.
Puerto Rico has shown us what can happen when this disinvestment is allowed to continue unchecked. Every death on the island is an indictment of years of political failure to foster health by improving conditions in the region. And it’s a tragedy and a cautionary tale for what our collective future will look like if we continue to follow the path the Trump administration has chosen.
Sandro Galea is a professor and Dean of Boston University School of Public Health. His book, Healthier: Fifty Thoughts On The Foundations Of Population Health, was published in June. Follow him on Twitter: @sandrogalea.