by Jonathan Heller

The determinant of health that likely has the greatest impact on public health and health equity may be something most public health professionals have the least to say about in their professional capacities: the ideological direction of the country. We are at a pivotal point in history; the old ideological paradigm – neoliberalism, the latest incarnation of racialized capitalism – is dying and we are in the midst of a struggle over what new paradigm will replace it. The consequences for health and health equity are enormous. Engaging in this struggle, alongside other social movements, arguably will be the highest impact action we can take to improve health and advance health equity. 

Evidence shows that the social determinants of health – housing, transportation, employment, education, etc. – have a huge influence on our health. Those suffering from health inequities most often face inequities in multiple determinants of health; they live, for example in low-opportunity neighborhoods with poor schools, few good job opportunities, and high levels of environmental pollutants. Public health has been becoming more aware that these inequities in the determinants of health result from a power imbalance between those who benefit from the status quo and those who are harmed by it, as well as from structural racism and other forms of oppression. 

One form of power, albeit an invisible one, is the ability to shape people’s conscious and unconscious understanding of the world. This includes what people think is meant by fair and optimal living conditions, systems, and processes, and who has the right to health and opportunity, and the role of government in achieving this. This is the form of power that shapes worldview or ideology, and it defines what is possible and what is not in terms of changing policies, systems, and environments.

The dominant ideology – the ideology most people in the country hold – has shifted dramatically over our country’s history and this has powerfully shaped our direction. Most recently, what many call a social democratic capitalist era that took hold after World War II was replaced by a neoliberal era during the 1970s. Neoliberal ideology can be characterized by unfettered free markets, limited government, a focus on scarcity, and individualism, packaged together with racism. Two significant outcomes of neoliberalism over the last 40 years are historically high levels of wealth inequality and deep cuts in our social safety net. These have, in turn, led to poor health and health equity outcomes, including those described by Case and Deaton as “deaths of despair” and those described by Wilkinson and Pickett in The Spirit Level. 

The housing and economic crash of 2008 marked the beginning of the demise of the cognitive capture of neoliberal ideology; many people began seeing its shortcomings and it lost its power to explain to people how the world should work. The popularity of the Occupy Wall Street slogan “We are the 99%” exemplifies this loss of power, rejecting wealth inequality and corporate greed. Our country’s failed response to the COVID-19 pandemic marks another crack in the dominance of neoliberalism, with many people now seeing that we are truly interdependent as well and understanding the need for government in terms of a coherent public health response and an economic safety net. High levels of support – 75% in some polling – for the $1.9 trillion American Rescue Plan are another demonstration of the loss of neoliberalism’s hold over us.

However, what replaces neoliberalism is being highly contested in this moment, with two broad directions seemingly emerging as most likely. The past four years, culminating in the January 6 insurrection, have been a demonstration of one of those paths: authoritarianism. Supported by so-called alternative facts, this path includes: limiting our democracy and rule by a minority; a continued upward transfer of wealth and greater economic inequality; the use of racism and other forms of oppression to maintain power for a predominantly wealthy, white, male elite; criminalization of those who are “othered,” such as immigrants and trans people; and climate change denial. Public health evidence shows us clearly that this direction will result in huge negative health and health equity impacts.

The second path that is emerging is a return to a social democratic ideology, but one that is more racially just and climate conscious than the post war version. This path would include: tax increases on the wealthy and deep investment in communities of color; increased regulations of corporations and more powerful worker organizations; an expansion of the social safety net; actions to slow and mitigate climate change; and fixes to our criminal justice and immigration systems. It would be grounded in: participatory, active democracy; radical inclusion; care for one another; creating an economy that serves human and social development; a view of our environment as sacred; and the understanding freedom should serve everyone reaching their full potential.  Public health evidence from the last several decades demonstrates that this direction would likely result in positive health impacts and a reduction of health inequities.

Social movements are building on both sides of this struggle to replace neoliberal ideology. The outcome is anything but certain.

There are a number of ways for public health to engage in this debate over our country’s future, including, for example, by partnering with community organizing groups that build power with those most harmed by current inequities. Another concrete action is to engage in transforming public narratives, the values-based meta-stories about how and why the world operates that have the ability to shape public consciousness, including our collective senses of responsibility and possibility.

Which of these ideological paths we choose as a society will define the systems and environments in which we as public health professionals work. The choice will have a greater impact on health and health equity than anything we can do as individual public health professionals and as public health institutions. Ignoring or not engaging in this struggle with these other social movements is not just a missed opportunity, it is a dereliction of our duty as public health practitioners.

Jonathan Heller is a Senior Health Equity Fellow at the University of Wisconsin Population Health Institute. Previously, he co-founded and co-directed Human Impact Partners.