Seeing the Whole Field: Balancing Health Goals in Policymaking

I was raised in a football family. Not that anyone played. We were Washington, DC, NFL fans, with Sundays consumed by the team now called the Commanders. As a little girl, I had a poster of the referee signals on my bedroom wall, perhaps an early indicator that I would have a career in policy. We spent our family time together second-guessing Coach Joe Gibbs and cheering on fullback John Riggins, creating a sense of belonging in our community and family rituals that we still enjoy today.

As we approach Superbowl Sunday, I am thinking about what American football tells us about health policy. Based purely on medical evidence, a responsible health policymaker would cancel the whole league. Powerful young men (and Aaron Rodgers) slam into each other, knock each other down, cause real harm…from torn ACLs to serious concussions and CTE.

Deb Lubar and her son at a Commanders game.

But here we are: Superbowl 60, Patriots vs. Seahawks, East vs West, a game that I hope will be as exciting as the same match up 10 years ago. Nearly the whole country participates, even if it’s just for the commercials and the half-time show. And here’s why: health is an important consideration, but it’s not the only one. Football connects us to our neighbors. It gives us a way to bond with family and make new connections. It gives thousands of young men the opportunity for higher education and financial success. It generates enormous economic activity and supports whole industries. These are valuable benefits, and as a society, we have accepted the risks that come with them.

Rather than banning the sport, we have turned to science to reduce its harmful health effects. These precautions are not perfect and should continue to advance. If we look at Superbowl I in 1967 (actually called the AFL-NFL World Championship Game), we see a very different game, both in terms of rules and protective gear. Facemasks had only been required five years prior, and Bart Starr didn’t yet have the protection of the “in the grasp” rule preventing quarterback tackles after the whistle. His pads and protective gear were about half the size of modern gear. He was still the MVP, leading the Packers to a 35 to 10 victory over the Chiefs.

Often in health policy, science can be mistaken as the only consideration. Yet, incorporating evidence and data into decisions is complex, and science rarely gives us only one possible path. Policymakers need to collaborate with scientists who understand they are balancing data and health outcomes with other values and considerations. In my policy work at the Centers for Disease Control and Prevention (CDC), I was privileged to partner with world-class scientists to incorporate these factors into CDC’s programs and policy. Strong science gave us information about what worked to achieve health benefits, and that starting point allowed us to engage with constituents and policymakers about other factors, including feasibility, acceptability, economic effects, and consider how the options align with ethics and equity. When evidence-based policymaking is at its best, these considerations are explicit and transparent.

To develop a new process for evidence-based guidance at CDC, I led a team that built on the Evidence-to-Recommendations framework, long employed by the Advisory Committee for Immunization Practice (ACIP) until recent changes. We created the first agency-wide guidance process for systematically considering multiple sources of evidence alongside contextual factors, with clear expectations for transparency. Using this new framework, CDC released an action guide for promoting mental health and well-being in schools, updated advice to physicians counseling patients about PFAS chemicals, and provided heat and health recommendations to families of children with asthma.

For those families, I remember weighing the recommendation that kids stay indoors on the hottest days with the benefits of outdoor play and the fact that in some communities, most days in the summer qualify as “hottest days.” This balancing act resulted in information that parents could use to protect their child’s respiratory health and their overall well-being using real-time local HEAT and health data and evidence-based recommendations for action, based on their own risk tolerance and values. Schools and other organizations can also use these tools to set policies for health and safety.

These complex decisions are not likely to please everyone affected. Even we football fans wish there were fewer injuries and more protection for players. Yet, what would we lose if we cancelled the Superbowl? Instead, we take the risks with the benefits. Balancing health, safety, community, freedom, and so many other important values is what policymakers have to do every day.

This is what brought me to the Milbank Memorial Fund — the chance to work with policymakers and experts on policies that support population health. I’m engaging with partners to inform how Milbank moves forward in a time where health policy is more challenging than ever, and what I’m hearing is that state and local leaders are deluged with urgent needs, from starting Rural Health Transformation programs, to planning for Medicaid changes, to taking on more public health responsibilities as the federal government’s capacity has decreased. Timelines on these pressing needs are short, yet leaders still need to incorporate evidence, engage with the public, and be transparent about their process as they make decisions. Now is a time to come together on the urgent needs as well as seize opportunities to improve the long-term health and well-being of our communities, so we can cheer on our favorite teams together. Or, for Commanders fans, look forward to next year.