Infrastructure

March 2017 | Howard Markel | From the Editor-in-Chief

On the campaign stump, Donald J. Trump often spoke about his trillion-dollar plan to “transform America’s crumbling infrastructure into a golden opportunity for accelerated economic growth and more rapid productivity gains with a deficit neutral plan targeting substantial . . . investments in transportation, clean water, a modern and reliable electricity grid, telecommunications, security infrastructure, and other pressing domestic infrastructure needs.”1

When reading these words, one is almost reminded of the Works Progress Administration (WPA), the largest program in Franklin Delano Roosevelt’s New Deal, begun during the depths of the Great Depression.

Think again, says the Nobel prize–winning economist and New York Times columnist Paul Krugman:

It’s not [Mr. Krugman’s italics] a plan to borrow $1 trillion and spend it on much-needed projects — which would be the straightforward, obvious thing to do. It is, instead, supposed to involve having private investors do the work both of raising money and building the projects—with the aid of a huge tax credit that gives them back 82 percent of the equity they put in. To compensate for the small sliver of additional equity and the interest on their borrowing, the private investors then have to somehow make profits on the assets they end up owning.2

The WPA, conversely, represented the federal government’s investment in both its infrastructure and the American people, especially those most hurt by the Depression. As FDR’s federal relief administrator, Harry Hopkins, famously said, “Give a man a dole and you save his body and destroy his spirit. Give a man a job and you save both his body and his spirit.”

The results were phenomenal. More than 8.5 million (mostly unskilled male) workers were hired by the WPA at a monthly salary of $41.57 to build over 650,000 miles of roads and 700 miles of
airport runways, 78,000 bridges, and “85,000 improved buildings . . . [including] 5,900 new schools; 9,300 new auditoriums, gyms, and recreational buildings; 1,000 new libraries; 7,000 new dormitories; and 900 new armories.”3 Other WPA projects included the construction of “2,302 stadiums, grandstands, and bleachers; 52 fairgrounds and rodeo grounds; 1,686 parks covering 75,152 acres; 3,085 playgrounds; 3,026 athletic fields; 805 swimming pools and 848 wading pools; 1,817 handball courts; 10,070 tennis courts; 2,261 horseshoe pits; 1,101 ice-skating areas; 228 band shells and 138 outdoor theatres; 254 golf courses; and 65 ski jumps.”3 The price tag for these projects from the passage of the Emergency Relief Appropriations Act in January 1935 through June 1941 was roughly $11.4 billion, or even more roughly in today’s dollars, more than $190 billion. The value of these good works to American society and culture is incalculable. Indeed, many Americans still benefit from the fruits of the WPA’s labor, including travelers utilizing the Ronald ReaganWashington National Airport and LaGuardia Airport and automobile drivers on the San Francisco–Oakland Bay Bridge, New York City’s Lincoln Tunnel, and the Florida Keys Overseas Highway.3,4

Less heralded, but equally important, was the WPA’s work devoted to “health conservation.” This federal program was responsible for spurring the creation of hundreds of primary care clinics; orchestrating mass educational campaigns promoting health and the early detection of diseases, ranging from sexually transmitted infections to cancer; building hundreds of hospitals; developing community sanitation programs to thwart the spread of diarrheal and water-borne diseases; delivering millions of immunizations and home nurses’ visits; and even initiating the school lunch program so no child would have to learn on an empty stomach. On the research side of the equation, the WPA granted the US Public Health Service funding to create the National Health Survey. In the first iteration of this still critical survey, more than 2 million Americans were discovered to have serious, untreated illnesses they did not know about. Millions more suffered from the disabling consequences of chronic disease, but they had few if any options for treatment.

 

WPA Federal Art Project poster from the Library of Congress
Prints and Photographs Division, Washington, DC.

In a 1939 radio speech, sponsored by the Daughters of the American Revolution, Assistant WPA Commissioner Florence Kerr kept her audience spellbound as she described the health conservation division’s work. Examining the extant copy of her radio script, her words seem especially apropos in the wake of last year’s lead poisoning crisis in Flint, Michigan, and the measles epidemic among unimmunized children in Orange County, California:

For well over fifty years public health officials and sanitary engineers have been carrying on one of the most remarkable battles in history–and it has been a battle every inch of the way–to make every city, town and village in the United States of America safe for our people to live in. These men have fought against ignorance and smugness. They have fought against local selfishness and national inertia. They have worked and schemed and planned and overcome, until finally they have made us understand that we needed our modern reservoirs, our modern disposal plants, our systems of water supply and purification plants; that we must have more hospitals and better equipment; that the lower income groups among us are not getting the medical treatment they need and that their children are dying at a rate that is a disgrace to society. I cannot tell you how much we owe to these public health officers and sanitary engineers, because nobody could tell that. But one of the things I want to make clear is that for four years the WPA has had the privilege of placing at the disposal of these forward looking leaders a great many of our workers. Under their direction, we have carried on work that has made the health of thousands of communities better and safer than it could otherwise have been. The essence of the WPA program is cooperation. It is ready with the workers to help public-spirited citizens make their communities better places to live in. People in this country do not need to take their desires for better sanitation out in merely wishing. They can help turn the hopes and dreams of sanitary engineers into realities. They do not need merely to wish that it were unnecessary for thousands of cases of serious illness to remain untreated. They can and should see that medical and nursing services are extended to a larger number of people who cannot pay for them.5

Remarkably, in the midst of one of the most ambitious construction projects ever undertaken, as Commissioner Kerr observed on that long-ago morning, the WPA was creating and disseminating a wealth of healthy ideas and programs. The wider historical lesson is how the WPA helped make America healthier and greater, not with tax incentives lining the pockets of private-sector builders but with significant investments in our citizenry, bearing the full faith and credit of the US Treasury.

If President Trump intends on fixing our “crumbling infrastructure,” and we sincerely hope he does, health care professionals, health policymakers, and population health scholars must be willing to get involved in the political fray. Armed with evidence-based analyses and clinical or administrative experience rather than polemics or punditry, we have the power, expertise, and responsibility to remind the president of the importance of protecting our nation’s greatest infrastructural asset: the health of and access to health care for every American man and woman, girl and boy.

* * *

We begin our March issue with a guest op-ed by Margaret Chan, director-general of the World Health Organization. This past October, Dr. Chan delivered a superb keynote address at the 2016 annual meeting of the National Academy of Medicine on the “slow-motion epidemic” of diabetes. Her essay is drawn from those remarks. Our second guest columnist is David Blumenthal, president of the Commonwealth Fund. From 2009 to 2011, he was the national coordinator for health information in the Obama administration. In this capacity, he oversaw the development of a national, interoperable, private, and secure health information system. His Op-Ed explores the problem of patients withholding clinical data in the age of digital health.

We then turn to our regular op-ed columnists, who offer some superb observations on population health and health policy, as well. Lawrence Gostin reviews the rise of new laws enacting sugary soft drink taxes; Joshua Sharfstein comments on how ill-equipped both the medical profession and the health care industry are to ameliorate the current opioid and opiate addiction epidemic, despite evidence of treatment plans that can make a huge difference; Sara Rosenbaum writes about contraception as a health right and upcoming Supreme Court decisions on that issue; Gail Wilensky discusses the many permutations of the congressional movement to “repeal and replace” the Affordable Care Act of 2010; David Rosner considers the relationship of health, climate
change, and the descent of science-based policymaking; and Catherine DeAngelis discusses the role we all should play in clinical trials as a means of improving population health.

We then proceed to the issue’s original contributions:

  • “Beyond Health Insurance: Remaining Disparities in US Health Care in the Post-ACA Era” by Benjamin D. Sommers, Caitlin L. McMurtry, Robert J. Blendon, John M. Benson, and Justin M.
    Sayde
  • “Treating, Fast and Slow: Americans’ Understanding of and Responses to Low-Value Care” by Mark Schlesinger and Rachel Grob
  • “Information Blocking: Is It Occurring and What Policy Strategies Can Address It?” by Julia Adler-Milstein and Eric Pfeifer
  • “Measuring, Reporting, and Rewarding Quality of Care in 5 Nations: 5 Policy Levers to Enhance Hospital Quality Accountability” by Christoph Pross, Alexander Geissler, and Reinhard
    Busse
  • “Value-Based Physician Payment in Oncology: Public and Private Insurer Initiatives” by James C. Robinson

* * *

We hope that this issue of The Milbank Quarterly serves as a much-awaited herald of spring and a valuable source of evidence-based health policy and population health.

On an even more hopeful note, the poet-physician (and tuberculosis patient) John Keats (1795-1821) reminds us that we still have much to sing about this spring of 2017, albeit in a poem entitled “To Autumn,” written 198 years ago:

Where are the songs of Spring? Ay, where are they?
Think not of them, thou hast thy music too,–

References

  1. Infrastructure: Donald J. Trump’s vision. Donald J. Trump website. https://www.donaldjtrump.com/policies/an-americas-infrastructure-first-plan/. Accessed November 25, 2016.
  2. Krugman P. Infrastructure build or privitization scam? The Conscience of a Liberal blog. New York Times. November 19, 2016. http://krugman.blogs.nytimes.com/2016/11/19/infrastructure-build-or-privatization-scam/?emc=eta1. Accessed November 27, 2016.
  3. Leighninger RD Jr. Cultural infrastructure: the legacy of the New Deal. Journal of Architectural Education. 1998;49(4):226-236.
  4. Kennedy DM. Freedom From Fear: The American People in Depression and War, 1929-1945. New York: Oxford University Press, 1999:249-287.
  5. Kerr F; Daughters of the American Revolution. Health conservation and the Works Progress Administration [transcript].WJSVStudios, Washington, DC, at 9:30 a.m., Eastern Standard Time, Saturday, October 21, 1939. http://socialwelfare.library.vcu.edu/eras/great-depression/health-conservation-and-the-wpa/. Accessed November 25, 2016.

Howard Markel is the editor-in-chief of The Milbank Quarterly. He is also the George E. Wantz Distinguished Professor of the History of Medicine and director of the Center for the History of Medicine at the University of Michigan. An acclaimed social and cultural historian of medicine, Dr. Markel has published widely on epidemic disease, quarantine and public health policy, addiction and substance abuse, and children’s health policy. From 2006 to 2016, he served as the principal historical consultant on pandemic preparedness for the U.S. Centers for Disease Control and Prevention. From late April 2009 to February 2011, he served as a member of the CDC director’s “Novel A/H1N1 Influenza Team B,” a real-time think tank of experts charged with evaluating the federal government’s influenza policies on a daily basis during the outbreak. The author or co-author of ten books and over 350 publications, he is editor-in-chief of The 1918–1919 American Influenza Pandemic: A Digital Encyclopedia and Archive. He received his AB (summa cum laude) and MD (cum laude) from the University of Michigan and a PhD from the Johns Hopkins University. He completed his internship, residency, and fellowship in general pediatrics at the Johns Hopkins Hospital. In 2008, he was elected a member of the Institute of Medicine of the National Academy of Sciences.