What Should We Be Teaching Our Students in 2025?
What Should We Be Teaching Our Students in 2025?
That excess deaths are a public health problem—and students should grapple with how to increase the number of people living healthier lives.
There is a formidable array of national public health problems, and the total burden is not diminishing. At the center of this swirl is the fact that US life expectancy, an index of these many problems, has been falling behind peer, high-income countries’ for the past 40 years and has particularly languished in the last decade. Incredibly, there were more “missing Americans” in 2021—the number of deaths that would have been averted if the United States had the mortality rates of our peers—than in any year going back to 1933. Between 1980 and 2019 there were an estimated 11 million total excess US deaths that would have been prevented if the US had mortality rates equal to the average of peer countries. If we are prioritizing what students need to learn during the precious few years of public health training, we should feel obliged to focus students’ classroom attention on why are we dying prematurely, and what can we do about it?
Where do we turn to try to get explanations for this existential concern? Social drivers of health are indeed part of the curriculum of every public health school. The ancient dilemmas of poverty, crime, unemployment, racism, and illiteracy all influence health and early death. Yet these are all large, painfully complex social issues, so public health scholars also look to more proximate causes that might be more readily addressable. Particularly important in the US are overdoses, firearm injuries, and vehicle accidents; hazards that are a bit “newer,” less studied, and recently on the rise, most notably for younger adults under the age of 45.
But, in fact, the leading causes of death across all American adults over the past 40 years are circulatory diseases (41 percent of total). Hauntingly, about half of our “missing” Americans die in mid-life between 45 and 65 years old, producing psychological upset and economic shakiness for surviving children and family.
If we were to pick a single set of illnesses that are the major contributors to the US survival gap, circulatory diseases that affect the heart and major blood vessels—heart failure, stroke, hypertension—would be it, rather than drug poisonings, alcohol-related deaths, and suicide (13 percent) and transportation accidents (5 percent). Dementia and climate change will rise in the rankings of causes in the years ahead. But for this decade’s students, graduating public health school without deep knowledge of how public health thinking matters when addressing these causes of our population’s shortened life expectancy, would be a shame.
Circulatory diseases are behavioral and often diet-related diseases, the downstream harms of industrial agriculture and food processing. These businesses are in the sight line of the Make America Healthy Again agenda (it goes without saying that “healthy again,” is a misnomer given the overall trends in lifespans across the US). Although the end-stage of circulatory conditions frequently lead to hospitalization, excess deaths are a public health problem, not a medical delivery problem. That the US has higher death rates than countries with similarly advanced medical technologies tells us medicine and taking care of those among us who are already sick, will not allow the US to find the missing Americans.
The only way to avoid these excess US deaths, to lessen our chronic, health-related disabilities and increase our life expectancy, is to adopt public health and social policies that have benefited peer countries. There are ways to prevent diet-related illnesses like obesity and diabetes that lead to heart disease. The difficulties to implementation are formidable, and would not be met without backlash from economic arguments to personal freedom infringement. It has not been that long since the end of Michelle Obama’s healthy school lunch advocacy or Michael Bloomberg’s large-soda ban. But analyzing proposed solutions, trade-offs, and challenges are exactly what our public health students should do each and every day.
In the limited number of classroom hours that produce an MPH degree, students should grapple with how to increase the number of people living healthier lives. In America, they should interrogate the deep roots in economics and culture that have led us to this current moment. As should our political leaders, who will need to commit themselves to prevention and uncomfortable truths if they are truly interested in making America healthy.
Michael Stein, MD
Dean Ad Interim
Boston University School of Public Health
mdstein@bu.edu
Previous Public Health Matters are archived at: https://www.bu.edu/sph/news/articles/category/public-health-matters/
