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December 2017 (Volume 95)
Quarterly Article
Joshua M. Sharfstein
December 2024
Dec 19, 2024
Back to The Milbank Quarterly
Every day, people make decisions that risk their health, such as smoking cigarettes, eating poorly, failing to exercise, and ignoring urban planning.
Urban planning?
“No city could have withstood [Hurricane] Harvey without serious harm, but Houston made itself more vulnerable than necessary,” wrote Peter Coy and Christopher Flavelle in Bloomberg Businessweek. “Paving over the saw-grass prairie reduced the ground’s capacity to absorb rainfall. Flood-control reservoirs were too small. Building codes were inadequate.”1
These ill-advised steps, including the repeated rejection by voters of a basic zoning system, are what made the scale of the Hurricane Harvey disaster so epic. Thousands of homes built on floodplains were destroyed. “You would have seen widespread damage with Harvey no matter what, but I have no doubt it could have been substantially reduced,” Jim Blackburn, a Rice University expert on extreme weather, told the Washington Post.2
What if Harvey were not a hurricane, but instead a 55-year-old low-income man suffering from complications from adult-onset diabetes? There are some who would show little sympathy for his predicament. Physician and Kansas Congressman Roger Marshall has opposed providing health coverage to poor people who “do probably the least preventive medicine and taking care of themselves and eating healthy and exercising.” Mick Mulvaney, the director of the Office of Management and Budget in the White House, has questioned providing care to someone “who sits at home, eats poorly and gets diabetes.”3
In the case of Hurricane Harvey, however, the Trump administration sought and won congressional approval of $7.4 billion in direct assistance within days. The person who asked? The same Mick Mulvaney, who informed Congress that “the Administration believes additional Federal resources are necessary to continue to fund critical, and often life-saving, response and recovery missions.”4
There appears to be a double standard at play. If there is plenty of responsibility to go around, why the broad support for some life-saving missions, such as those that affect regions, but not others, including many that affect individuals?
Certainly, one factor in public generosity is the concentration of the calamity. Hundreds of thousands of people in one place present a more compelling picture than do isolated households.
Another is the closeness of the connection that policymakers feel to the victims.Republicans and Democrats alike immediately supported efforts to aid the victims of Hurricane Harvey, which struck the great state of Texas. This generated some awkward questions for Texas Senators who had opposed the aid package for Hurricane Sandy, which hit the Northeast. (Then-Congressman Mulvaney from South Carolina did too, arguing then that spending cuts had to accompany emergency assistance.)
A third factor is discrimination, particularly when a health challenge affects marginalized groups. For decades, when addiction was perceived as disproportionately affecting low-income and minority groups, many policymakers treated those who were suffering more as criminals than as patients. Now that the problem has spread into rural and suburban white communities, there is bipartisan interest in expanding access to treatment and identifying ways for law enforcement personnel to divert individuals away from prison.
A fourth factor is perhaps the most relevant for the disparity in the approach to health challenges facing individuals versus those facing large geographic areas: the degree to which politics complicates understanding the link between decisions and consequences.
Many policymakers feel comfortable blaming Harvey the man for his diabetes because there is broad understanding of the relationship between weight gain and the disease. But the same politicians may see Hurricane Harvey as unpredictable and unmanageable. They refuse to accept the scientific evidence on climate change and reject the premise that unfettered growth can have dire consequences. In Houston, local officials disregarded local scientists who pointed out that development policies were putting the area at risk for a catastrophic flood. The longtime head of the flood control district explained why by saying that the scientists “have an agenda . . . their agenda to protect the environment overrides common sense.”5
What would happen if these various considerations and biases did not exist? In other words, what would happen if society took the same approach to Harvey, the 55-year-old man with diabetes, as to Harvey the hurricane?
One option would be for government to deny assistance to all those suffering the consequences of poor decision making. This would leave Harvey the patient without essential care for his diabetes, suffering from painful complications and likely to die prematurely. It would also leave Houston devastated for years to come.
Unlikely.
A second option would be to ignore questions of responsibility altogether and generously fund treatment and recovery—for both Harvey the man and for Houston. And if the problems were to recur again and again, to do the same. Patients and city councils might learn their own lessons—or not.
Maybe.
The third option would be a middle path—support necessary care and disaster relief, but couple it with education about what happened and how to prevent or mitigate a recurrence. This option would also include the pursuit of policies that support better decisions, by, for example, using zoning codes both to expand access to healthy foods and to reduce ill-advised construction on floodplains. If problems were to recur, society could remain generous in the response while seeking out more effective ways to affect behavior in the future.
This third path reflects a public health approach. And if both Harveys were to be treated equally, it might represent a common ground for a path forward.
Of course, it will be challenging in our era of great division to come together on issues of responsibility. For one reason, it is hard to imagine broad recognition of the similarities between a man with elevated blood sugar and a raging hurricane.
But not as hard as one might think. Frustrated that Environmental Protection Agency Administrator Scott Pruitt said during Hurricane Harvey that the time to talk about climate change “isn’t now,” musician Mikel Jollet reached for an analogy to register his objection.
He tweeted: “Doctor: You have diabetes. Scott Pruitt: Whoa there. This isn’t the time to talk about sugar.” This message was retweeted 22,000 times.
So here’s a modest proposal: For every named weather event, health agencies should find a local homonymous patient in need of assistance to volunteer to tell his or her story. Irma might be seeking addiction treatment, and Jose might be looking for medication to control high blood pressure.
The goal would not be to generate confusion about which Irma or Jose needed a response. It would be to help people see the benefits of both treatment and prevention for all of those dealing with the consequences of poor decisions.
References
Joshua M. Sharfstein is associate dean for public health practice and training at the Johns Hopkins Bloomberg School of Public Health. He served as secretary of the Maryland Department of Health and Mental Hygiene from 2011 to 2014, as principal deputy commissioner of the US Food and Drug Administration from 2009 to 2011, and as the commissioner of health in Baltimore, Maryland, from December 2005 to March 2009. From July 2001 to December 2005, Sharfstein served on the minority staff of the Committee on Government Reform of the US House of Representatives, working for Congressman Henry A. Waxman. He serves on the Board on Population Health and Public Health Practice of the Institute of Medicine and the editorial board of JAMA. He is a 1991 graduate of Harvard College, a 1996 graduate of Harvard Medical School, a 1999 graduate of the combined residency program in pediatrics at Boston Medical Center and Boston Children’s Hospital, and a 2001 graduate of the fellowship program in general pediatrics at the Boston University School of Medicine.
