To understand how the US budget process disincentivizes long term public health investment it is important to first know the 4 types of spending.

Based on our political process the spend later benefit now approach is highly incentivized. This entails adding to the national debt for a current benefit. Politicians are driven to give their electors promises of services without added taxes in order to get and stay elected. The issue with this infrastructure is that it disincentives long term investments such as preventative public health measures and burdens future generations with costs they don’t benefit from.

I am currently also in a federal and state budget seminar at the law school (taught by Professor Lawrence, head of the health law program) and we have discussed this issue a lot. One of the solutions we keep coming back to is setting legislation to take affect around 10 years in the future surrounding reducing deficit spending or investments. This method allows for whatever party is in power to not tie the decision to their political capital. One hurdle with this is an issue called entrenchment, which is basically taking decision making out of the hand of future officials.

I’d be interested to hear about approaches to solve this issue from a public health perspective. As we saw with the COVID-19 pandemic underinvestment in public health measures is a huge issue and due to that we are further burdening future generations with the debt that resulted from expenditures.

 

The topic of death and dying rang in person to me as I lost my grandfather from a non-covid related condition this past August. Having experienced him becoming ill briefly before the pandemic and then worsening during, I found myself and my family stuck at a crossroads of making safer choices to potentially lengthen his life and wanted to be with him to provide love and care during this difficult time. The experience we had is not unique as many families and terminal patients found themselves with the same dilemma

This poses a question of when should individual wishes be prioritized over public health measures. With many states recognizing the right to die and refuse care as an individual right, it is not a far stretch to think there should be some room to accept risk of exposure during a pandemic. While I cannot entirely speak from the patient perspective I imagine if I were myself in that position I’d find more value in being surrounded in those I care about in my end time (whether that be years, months, or days) than I would in extending my lowered quality of life.

The policy perspective primarily surrounds those patients receiving longterm care within medical facilities. This differs from my personal experience with my family member who would commute to receive care and reside at home. In cases similar to that of mine it falls on the individual families to make decisions based on recommendations however, I found that these recommendations imposed guilt if not followed even to that of my grandfathers wishes. Having been through this experience I find that there is a place for a voice in the public health field that acknowledges that sometimes individual wishes should prevail over the “best” health measures. In times of mass death it is important to not forget that these people are not just statistics but independent people with unique experiences.

While not unique but rather exasperated by covid, academic burn out specifically in professional students continues to come to new peaks. In my personal experience this comes from academic institutions and students having often unaligned interests when it comes to early career placements. Specifically in the emory law school career services is designed to place the top students with the most prestigious and high paying jobs that they are able to form recruitment partnerships with. Students in lower rankings within their class have their preferences overshadowed by university preference to take the highest paying job possible given their credentials. These jobs that students are steered towards are likely not within their desired specializations which leads to a harmful message that either be top of the class or you’re not good enough. Whatever options are available to lower ranked students are often very niche and also competitive due to the largest student base being qualified for them. Whats left is a hole in how students are able to pursue their interests without being top of the class.

As mentioned in this weeks class a lot of this stems from systematic pressures driven by capitalism. Capitalism inherently drives us to constantly be competing, with historically employers having the highest bargaining power. Employers bargaining power transfers to institutions and then is passed on to create an immensely competitive culture with students leading to high stress levels and strained mental health. Prior to pursuing my law degree I worked in an accounting firm that exemplified this capitalistic culture to a tee. Within that company skipping lunch breaks and committing to long periods of overtime were rewarded with accolades while work flexibility, balance, and pay transparency were discouraged. As a result of the culture there, as well as the one we experience academically, we are constantly pushed to work more, to do the most, and in turn be conditioned to provide the most value to employers. So when firms are partnering with academic institutions to give their top students high salary positions they are essentially following predictable economic motives to get the most bang for their buck. And in the time when current partners were in our position this method didn’t pose problematic due to general lower cost of living and a larger thriving middle class.

What the issue is now is that is compounding that pressure is a high spike in cost of living due to covid driven inflation. During the period of reduced production, supply in many sectors was depleted while we are now experiencing once again high demand. Companies are taking advantage of demand by hiking up prices so that they still experience annual revenue growth and by making investments that are pushing the American dream further and further from reality (real estate investors capitalizing on financial hardship through foreclosure buys). To translate a lower and lower percentage of the population is hoarding more and more of the wealth. This creates the academic stress that we discussed of not necessarily finding the “best” job but rather finding a job that can sustain our expenses and then factoring in how that job aligns with our goals and happiness. So career services is behaving very predictably given current social and economic conditions. Another issue increasing in prevalence as a result is when students accrue debt in the pursuit of their passion, realize their passion is not feasible given their current debt load and projected expenses, and are locked into a profession concentration they are unhappy with. Given these conditions it is unsurprising the exponential increase in academic distress that Gary Glass highlighted.

While the great resignation did allow for some increase in bargaining power, the playing field is unlikely to be anywhere near level without some real systematic change. One path to igniting this change is returning to actually previously present “maximum” wages regulated by progressive tax rates, free undergraduate education tuition, and corporate taxes that discourage wealth hoarding. Prior to the Reagan administration the largest marginal tax rate was 70% that he reduced to 50% through The Economic Recovery Act of 1981 and now is almost half of what it was at the start of his administration at 37%. While colleges have a history of fees, the word tuition used to be a relatively innovative concept with the University of Florida first charging in state students any tuition in 1969 and California not having any tuition until once again Reagan took office, but back when he was governor. If my political alignments were not already clear, I have some strong disagreements with our prior administration however I believe the phrase “Make American Great Again” does have some use and just needs to some revaluation of what America has done that was “great”.

Capitalistic culture is not swayed just by discussion around what is instead required is an extreme restructuring of incentives. Being that my perspective is limited to the fields of accountancy and law, I’m interested how these incentives present themselves in the medical and public health fields so please engage with comments.

 

https://time.com/4276222/free-college/: Education Burnout and its Capitalistic Origins

While covid-19 has transitioned employers to more permanently instating hybrid working models first introduced as pandemic measures, could this lead to further reforms to address employee burn out in the US? First it’s important to acknowledge how we came to the standard of the 40 hour work week in the first place. Originally passed in 1938 the Fair Labor Standards Act codified worker protections such as 44 (later amended to 40) hour work weeks and overtime compensation requirements. While at the time it was a huge success for industrial workers in a time of great wealth disparities between the upper and lower classes, why has it not been further modified to account for societal change and current disparities?

The above table provided by The Federal Reserve shows in green the top 1% share of wealth growing overtime since 1990, resulting in a smaller and smaller middle class. This growing inequality has been compared to levels during the US gilded age and the French Revolution but, due to less reliable data at those times it is difficult to confirm.

To translate how this relates to the growing demand for the four day work week, people are being overworked for less and less of market share and are realizing they are worth more. When the 1% profits off of underpaying and overworking employees to produce larger shares of wealth, the long told tale of the American dream is dying. With flexible work schedules as pandemic accommodations generally showing increased productivity and greater satisfaction, the transition “back to normal” is not happening without resistance. Along with the great resignation employees have played an uno reverse card on companies by taking back their bargaining power in numerous industries. Many roles such as teaching and nursing that cannot be performed from home are yearning for the flexibility that their peers have gained in their careers and with existing shortages, are in a position to not except otherwise. Below are some links that speculate on more of the benefits of the 4 day standard and I am excited to see where this goes.

https://www.mercer.com/our-thinking/career/four-day-workweek-the-cure-for-burnout.html https://fortune.com/2022/09/22/battle-for-talent-job-recruitment-4-day-week/ https://www.theguardian.com/commentisfree/2022/jul/29/could-long-covid-lead-to-the-rise-of-a-four-day-work-week

During a time when we’ve been accustomed to looking up to higher authorities, it was refreshing to hear of an approach of community involvement from Stacey Thurman. Her perspective of creating trust within communities by using public health advocates that are more familiar and accepted seems retroactively obvious. This begs the question of why did we go so wrong with COVID-19 communications, leading to the extreme politicization of public health unlike ever before. One answer may be due to the unprecedented and urgent nature of the pandemic however it also could be attributed to experts wanting to be the one to be accredited for the big breakthrough. A lesson I hope we learn from this disappointment is humility. Moving forward in public health matters, including for example the growing antivax movement, authorities need to collaborate within communities in order to mitigate politicization unearthing thought to be dead diseases. In times of mistrust and uncertainty it is much easier to villainize a stranger you only see in the media than it is to a local medical hero, nonprofit leader, MD in state office, and so on. As we go forward into our public health careers and scatter outside Atlanta into new horizons, Tulane has some advice on how we can advocate for public health. https://publichealth.tulane.edu/blog/community-health-advocate/