Sustainability as a Watchword for a New Era

Population Health

President Joe Biden hopes to husband a new administration and, perhaps, a new politico-economic era distinct from that of President Donald Trump and his free-market predecessors going back to Ronald Reagan in the 1980s. If a new era emerges, how might we define it? Is there a word? I nominate “sustainability.” Beyond the well-recognized arena of environmental sustainability, what the United States and the globe really need is a new era of societal sustainability.

In a June 2020 opinion, I considered how the last four decades had been defined and shaped by the aggressive free-market ideas of the late economist Milton Friedman and colleagues, also known as “neoliberalism.” Friedman’s ideas and prescriptions were legion: ever-shrinking government at all levels, constantly lowering taxes and less regulation, unleashed corporate profit-making for shareholders and no one else, economic freedom tied to plummeting equity, and much more. These ideas were robustly actualized in the United States during the Reagan years (1981-1989), in Great Britain by Prime Minister Margaret Thatcher starting in 1979, and in China by Premier Deng Xiaoping also in 1979. The emergence of this new era in the United States spelled the demise of the 48-year “New Deal” of President Franklin Roosevelt that had begun in 1933.

Neoliberal thinking has impacted the US health care system since the 1970s. The transition from public and nonprofit institutions to for-profit and investor-owned hospitals and other providers took off in the 1980s in a sustained way. The explosion of patient cost sharing in the form of deductibles, coinsurance, and copayments has roots in neoliberal ideas about consumers needing “skin in the game” to restrain their consumption of medical goods and services. Our society’s surrender on monopoly and corporate concentration came straight from the University of Chicago playbook, the home base of neoliberalism. Our record-breaking health spending tied to deplorable population health outcomes – from infant mortality to childhood and adult obesity to declining life expectancy – characterizes a system focused on maximizing revenues, not promoting health and wellbeing.

For better or worse, eras end, no matter how long-lived. While the November 3rd federal elections provided Joe Biden with far less than Roosevelt’s or Reagan’s tidal waves of support, a new era with different thinking is now well underway and all around us, if we care to look.

Defining and naming what comes next is challenging. What could replace neoliberalism/free market fundamentalism as a watchword for societal and health system refashioning? Thomas Kuhn, in his 1962 landmark book The Structure of Scientific Revolutions, recognized that the demise of one model demands replacement by another: “The decision to reject one paradigm is always simultaneously the decision to accept another.”

So, I humbly suggest that “sustainability” be the new watchword for the incoming Biden Administration, broadly interpreted above and beyond environmentalism. We have all heard the word used increasingly in recent years, and this bolsters its candidacy rather than undermining it. Compelling sustainability work has been going on for decades in the United States and globally. Perhaps the times now are ready to catch up with it. Two current uses stand out as especially prevalent: first, the environmental movement, especially and not exclusively in facing the challenge of climate change; and second, the United Nations’ Sustainable Development Goals (SDGs) for 2030.

Creating a sustainable environment is the most recognized, although neither new nor even recent. The US National Environmental Policy Act of 1969 does not use the word, but its language rings of sustainability: “The purposes of this Act are: To declare a national policy which will encourage productive and enjoyable harmony between man and his environment; to promote efforts which will prevent or eliminate damage to the environment and biosphere and stimulate the health and welfare of man; to enrich the understanding of the ecological systems and natural resources important to the Nation…”

The SDGs – the follow-on global goals to the UN’s 2015 Millennial Development Goals (MDGs) – recognize sustainability’s relevance including and beyond environmentalism. The 17 SDGs for 2030 were adopted by all United Nations member states (including the United States) in 2015, and represent a globally inspired call to action:

  1. No poverty;
  2. Zero hunger;
  3. Good health and wellbeing;
  4. Quality education;
  5. Gender equality;
  6. Clean water and sanitation;
  7. Affordable and clean energy;
  8. Decent work and economic growth;
  9. Industry, innovation, and infrastructure;
  10. Reduced inequalities;
  11. Sustainable cities and communities;
  12. Responsible consumption and production;
  13. Climate action;
  14. Life below water;
  15. Life on land;
  16. Peace, justice, and strong institutions; and
  17. Partnerships for the goals.

Environmental sustainability to address climate and related challenges is essential and not enough. We need economic sustainability that produces growth that benefits all Americans beyond the wealthy. We need tax sustainability that fairly distributes tax burdens to finance the government that people want and that ensures everyone pays their fair share. We need criminal justice sustainability that restores to society rehabilitated persons convicted of crimes. We need sustainable food and nutrition that deters overweight and obesity – the climate crisis inside our bodies. We need sustainable housing and communities that help families thrive. These are just starters.

One year ago, government leaders came together at the UN to consider SDG progress for the first time since the 2015 adoption. The United States was the only G-20 and OECD member state that refused to report its progress. A 2018 independent Sustainable Development Report of the United States offers a data-driven assessment of US progress and the lack thereof.

For the US health care system, sustainability is already connected to environmental challenges to limit the carbon imprints of hospitals, a major source of domestic carbon pollution. That’s just a starting point to align sustainability and our health care system, which is and always has been organized to cure and ameliorate illness and injury after harm is done. So much of our health care system’s excessive costs involve care for sick individuals after harm is done and not before.

While we decry the preposterous costs and inefficiencies of our health system, we also must recognize that the bulk of our people’s medical problems is tied to tobacco, alcohol, drugs, guns, obesity, and pollution. These are not the fault of medical providers, but they have become their responsibilities. The COVID-19 pandemic’s causes and effects were not the fault of our physicians and nurses, even though they have borne the brunt.

All over our nation, people are working to change the ruling US paradigm of competition, selfishness, and brazen self-interest. In sector after sector, including the dreaded finance community, attitudes, opinions, beliefs, and values are changing. Everyone has a role to play in saving the livability of our planet for our kids and grandkids. Every sector has a role to play and a mission to achieve. Sustainability doesn’t mean the end of growth – it means the pursuit of smart growth that recognizes our commonalities more than our differences. It recognizes that the self-destructive path of our global societies needs to shift, and fast.

Here in the United States, a new Biden administration has the opportunity to lead us toward a sustainable society. Let’s hope it does.

McDonough J. Sustainability as a Watchword for a New Era. Milbank Quarterly Opinion. January 28, 2021.

About the Author

John E. McDonough, DrPH, MPA, is a professor of public health practice at the Harvard University TH Chan School of Public Health in the Department of Health Policy and Management. Between 2008 and 2010, he served as a senior adviser on national health reform to the US Senate Committee on Health, Education, Labor, and Pensions, where he worked on the writing and passage of the Affordable Care Act. Between 2003 and 2008, he was executive director of Health Care For All, a Massachusetts consumer health advocacy organization, where he played a leading role in the passage of the 2006 Massachusetts health reform law. From 1985 to 1997, he was a member of the Massachusetts House of Representatives where he cochaired the Joint Committee on Health Care. His articles have appeared in the New England Journal of Medicine, Health Affairs and other journals. He has written several books including Inside National Health Reform in 2011 and Experiencing Politics: A Legislator’s Stories of Government and Health Care in 2000, both by the University of California Press and the Milbank Fund. He holds a doctorate in public health from the University of Michigan and a master’s in public administration from the Kennedy School of Government at Harvard University.

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