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California communities are banning syringe programs. Now the state is fighting back in court



California communities are banning syringe programs. Now the state is fighting back in court

As Indiana officials struggled to contain an outbreak of HIV among people who injected drugs, then-Gov. Mike Pence reluctantly followed the urgings of public health officials and cleared the way for an overwhelmed county to hand out clean syringes.

Pence was far from enthusiastic about launching the program in Scott County, but after it rolled out in 2015, the percentage of injection drug users there who said they shared needles dropped from 74% to 22%. Within a few years, the number of new HIV infections plummeted by 96% and new cases of hepatitis C fell by 76%.

The Sierra Harm Reduction Coalition wanted to keep those same diseases in check in California. The tiny nonprofit got approval from the state to deliver syringes in El Dorado County to prevent the spread of life-threatening illnesses.

Yet when the program was discussed at a December meeting of the county’s Board of Supervisors, the success story in Indiana held little sway. Faced with complaints about discarded needles and overdose deaths, the supervisors voted to prohibit syringe programs in the county’s unincorporated areas.

“These programs may work in other parts of California and throughout the United States, although I have my doubts,” Sheriff Jeff Leikauf said at the meeting. “El Dorado County does not want or need these types of programs.”


El Dorado is among a growing number of California communities that have banned syringe programs, testing the state’s power and political will to defend them as a public health strategy. It is part of a broader pushback against “harm reduction” — the practical philosophy of trying to reduce the negative effects of drug use — as overdose deaths have soared.

Now California is fighting back. In a recently filed lawsuit, the Department of Public Health argued that local ordinances prohibiting syringe programs in El Dorado County were preempted by state law, making them unenforceable.

The state is seeking a court order telling El Dorado County and the city of Placerville, its county seat, to stop enforcing their bans and allow syringe programs to resume.

An El Dorado County spokesperson said Monday that the county does not comment on pending legal issues. Its district attorney, however, said he was outraged to learn of the lawsuit, saying that state leaders were “seeking to impose the normalization of hardcore drug use.”

“Don’t come into our county and double down on your failed policy,” El Dorado County Dist. Atty. Vern Pierson said in a statement. “Allowing addicts to use fentanyl and other hardcore drugs is exactly what has caused other California counties to experience a death rate that is out of control and getting worse.”


Mona Ebrahimi, the city attorney for Placerville, said the city had put a 45-day temporary moratorium in place “to study the ongoing effects of syringe service programs in the city.”

“The city wants to protect the health, safety and welfare of its residents,” Ebrahimi said.

The California Department of Public Health has long endorsed handing out sterile syringes as a proven way to prevent dangerous infections from running rampant when people share contaminated syringes. Researchers have linked syringe programs with a roughly 50% reduction in HIV and hepatitis C.

“It sounds crazy: ‘Wait, you want to give out the tools to people to do this thing that we all agree is a bad idea?’” said Peter Davidson, a medical sociologist at UC San Diego. But it works, said Davidson, who called the programs “probably the best studied public health intervention of the last 70 years.”

Public health officials also see them as a crucial way to reach people who use drugs and link them to addiction and overdose-prevention services. In Seattle, for instance, researchers found that injection drug users who started going to a needle exchange were five times more likely to enter drug treatment than those who never went.


Signs direct visitors to the syringe-exchange program at the Austin Community Outreach Center in Austin, Ind., in 2015. The program was set up to curb an outbreak of HIV among people who injected drugs.

(Darron Cummings / Associated Press)

And in California, harm reduction groups have been particularly effective in getting Narcan — a nasal spray that can reverse opioid overdoses — into the hands of people who need it.

It’s “hugely important to reduce overdose in the community, and these are the programs that do that,” said Barrot Lambdin, a health policy fellow at RTI International who studies the implementation of health interventions.


Yet leaders in some cities and counties have strenuously rejected the health benefits of syringe programs.

In El Dorado County, local leaders asserted that the efforts of the Sierra Harm Reduction Coalition had not “meaningfully reduced” HIV or hepatitis C cases since its syringe program began four years ago and said the free needles were ramping up the risk of deadly overdoses, which they argued were a bigger threat.

Street scene shows trees with fall colors, cars and old buildings

The El Dorado County Courthouse in Placerville, Calif.

(Max Whittaker / For The Times)

Alessandra Ross, a harm reduction expert at the California Department of Public Health, disputed such arguments in a letter to county officials. Ross pointed out that in just one year, the coalition handed out more than 2,200 doses of medication to reverse opioid overdoses, saving at least 421 lives. Without the group’s efforts, she wrote, “El Dorado County could have potentially lost more than ten times as many people to overdose.”


Under state law, the California Department of Public Health has the authority to approve syringe programs anywhere that deadly or disabling infections might spread through used needles, “notwithstanding any other law” that might say otherwise.

The agency argued that the “significant state and public interest in curtailing the spread of HIV, hepatitis, and other bloodborne infections extends to every jurisdiction in the state, especially since Californians travel freely throughout the state.”

After El Dorado County prohibited syringe services in unincorporated areas, the state public health department adjusted its authorization for the Sierra Harm Reduction Coalition program, limiting its operations to Placerville. In the court filing, the agency said it made the change out of concern for the coalition’s staff and volunteers, who could be at risk of arrest if they provided syringes in the unincorporated areas.

The nonprofit said when it stopped providing syringes outside of Placerville city limits, roughly 40% of its clients were cut off. In February, Placerville city officials passed their own urgency ordinance banning syringe programs for 45 days, exempting needle provision at health facilities.

Ebrahimi, its city attorney, said officials took that step “after CDPH concentrated their use by authorizing them only in Placerville and nowhere else in the county.”


The Sierra Harm Reduction Coalition stopped providing syringes in Placerville as well, according to the state lawsuit. The coalition did not respond Monday to requests for comment on the suit.

El Dorado County and Placerville are not alone: A wave of local bans went into effect last year in Placer County after a harm reduction group from Sacramento sought state approval to hand out clean syringes. The county’s sheriff and its probation chief said in a letter to the state that the syringe program proposed by Safer Alternatives thru Networking and Education, or SANE, would “promote the use of addicting drugs” and lead to more “dirty needles discarded recklessly in our parks.”

The Placer County Board of Supervisors voted unanimously to ban syringe programs in its unincorporated areas. Cities including Auburn, Loomis and Rocklin banned them too.

“We are the ones who should make these kinds of decisions,” then-Mayor Alice Dowdin Calvillo said at a September meeting of the Auburn City Council, “and not allow the state to just bully us.”

Public health researchers stress that studies have found that free needle programs do not increase crime or drug use, or worsen syringe litter. Yet as much of Placer County became a no-go zone, SANE withdrew its application for a syringe program there.


“Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health,” said Ricky Bluthenthal, a USC sociologist whose research has documented the effectiveness of syringe programs. It doesn’t help that “the populations at risk are often marginalized or not politically active.”

Our political processes are not well set up for us to make reasoned, scientifically sound judgments about public health.

— Ricky Bluthenthal, a USC sociologist who studies syringe programs

The California Department of Public Health declined to address whether it planned to challenge local bans on syringe programs elsewhere in the state, saying it “cannot comment on active litigation strategy.”


Syringe programs have long faced public skepticism: In a 2017 survey, only 39% of U.S. adults said they supported legalizing them in their communities.

Experts say the programs have faced increasing jeopardy as public concern wanes about the threat of HIV and frustration swells over other problems like soaring numbers of overdose deaths and the spread of homeless encampments. Even in Indiana’s Scott County, local leaders voted three years ago to shutter its needle exchange.

Clashes are also arising because programs are making moves into new parts of California, bolstered in some cases by state funding. California officials also have taken steps to help syringe programs overcome local opposition, including exempting them from review under the California Environmental Quality Act.

“It’s not surprising that cities and counties are motivated to protect the public health and safety of their residents through whatever tools they have at their disposal,” said attorney David J. Terrazas, who represented a group that successfully sued to overturn state approval of a syringe program in Santa Cruz County.

In that case, a state appeals court ruled last year that the California Department of Public Health conducted an insufficient review of a program run by the Harm Reduction Coalition of Santa Cruz County. The department didn’t do enough to consult with law enforcement agencies in the area, among other shortcomings, the court said.


Although the state health department had considered some comments from law enforcement, “it never engaged with them directly about their concerns,” the appeals court concluded. Internal records showed department staff had decided not to respond to some of their comments and called one police chief an “imbecile.”

Terrazas said local officials are best poised to know what works for their communities. But Denise Elerick, founder of the Harm Reduction Coalition of Santa Cruz County, argued it made no sense for law enforcement to hold sway in public health decisions.

“We wouldn’t consult with them on what to do about COVID,” Elerick said.

A bag is filled with boxes of Narcan nasal spray for distribution to people living on the street in Los Angeles.

A bag is filled with boxes of Narcan nasal spray, one of several harm-reduction supplies distributed to people living on the street in Los Angeles.

(Francine Orr / Los Angeles Times)


Weeks after the court ruling, the state health department rolled back its approval for a syringe program in Orange County that would have been run by the Santa Ana-based Harm Reduction Institute, saying it wanted to consult more with local officials.

The decision was celebrated by city leaders in Santa Ana, who had banned syringe programs in 2020 and sharply opposed efforts to restart one. At a recent meeting, interim city manager Tom Hatch said a previous program was “an epic failure” that left its downtown littered with used syringes.

Orange County is currently the most populous county in the state without any syringe services programs — to the alarm of health researchers who found that syringe reuse increased after a local program was shut down.

The Santa Cruz court ruling was also invoked by the Santa Monica City Council, which directed city officials to investigate how Los Angeles County came to approve a program run by the Venice Family Clinic. That program sends outreach workers into Santa Monica parks once a week to offer clean syringes, Narcan and other supplies and connect people with healthcare, including for addiction.

A woman hands out Narcan to a man at Tongva Park in Santa Monica

Devon O’Malley, left, a harm reduction case manager with the Venice Family Clinic, hands out Narcan to Ken Newark at Tongva Park in Santa Monica.

(Mel Melcon / Los Angeles Times)


Critics want the program to relocate indoors, which they say would better protect parkgoers from discarded syringes. In addition, “if someone has to walk inside, there’s a chance for counselors to suggest strongly that it’s time for them to get off the drugs,” said Santa Monica Mayor Phil Brock, who wants the city to formally express its opposition to the program. “We can’t just facilitate their demise.”

Last month, a group called the Santa Monica Coalition filed suit to get L.A. County to halt the program it approved, saying it should instead be in a government building.

But Venice Family Clinic staffers said unhoused people can be reluctant to leave behind their belongings to go elsewhere. Even offering services out of a van reduced participation, said Arron Barba, director of the clinic’s Common Ground program.

“Bringing the service directly to the people is what we know works,” Barba said.

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Carbon Dioxide Levels Have Passed a New Milestone



Carbon Dioxide Levels Have Passed a New Milestone

Source: National Oceanic and Atmospheric Administration’s Global Monitoring Laboratory

The chart shows monthly numbers of carbon dioxide molecules per million molecules of dry air. Because of seasonal differences, levels are higher in May than in August.

Carbon dioxide acts like Earth’s thermostat: The more of it in the air, the more the planet warms.

In 2023, global levels of the greenhouse gas rose to 419 parts per million, around 50 percent more than before the Industrial Revolution. That means there are roughly 50 percent more carbon dioxide molecules in the air than there were in 1750.


As carbon dioxide builds up in the atmosphere, it traps heat and warms the planet.

More carbon dioxide, warmer temperatures

Source: NOAA (carbon dioxide); NASA (temperature)

The chart shows the change in global surface temperature relative to 1951–1980, versus global carbon dioxide levels. The dotted line shows the trend line.


Every additional amount of carbon dioxide in the atmosphere contributes to more warming, which is why climate scientists stress the need to get to zero emissions.

Currently, carbon dioxide levels are rising at near-record rates.

According to data released by the National Oceanic and Atmospheric Administration’s Global Monitoring Laboratory earlier this month, last year had the fourth-highest annual rise in global carbon dioxide levels.

Annual change in carbon dioxide levels

Source: NOAA’s Global Monitoring Laboratory


The chart shows the increase in global carbon dioxide levels over the course of each year. In 2023, they grew by around 2.8 parts per million.

The long-term rise in carbon dioxide levels is caused by burning fossil fuels, as well as other human activities such as deforestation and concrete production.

But there is also a lot of variation from year to year, which you can see in the chart above.

How much carbon dioxide levels rise in a given year depends on two factors: the amount of fossil fuels burned globally, and the share of these emissions that are absorbed by the land and the ocean.


Consider the first factor: While it’s true that clean energy production is rising globally, so is the demand for energy.

Fossil fuels have made up the difference. This is why global fossil fuel emissions are still at record-high values (with a brief dip during the pandemic). And they stayed high in 2023, according to a projection by the Global Carbon Budget.

Not all of these emissions end up in the air. The ocean and land absorb roughly half of the carbon dioxide that humans emit, while the rest stays in the air, said Glen Peters, a senior researcher at the CICERO Center for International Climate Research.

Where do carbon dioxide emissions go?

Source: Global Carbon Budget


The chart shows the net amounts of carbon dioxide emissions absorbed by the atmosphere, land and ocean. The emissions are produced by burning fossil fuels, deforestation and other human activities. Data does not include 2023.

That one-half figure is an approximation. It varies from year to year depending on weather conditions and other environmental factors, resulting in the jagged lines you see in the chart above. For example, in a warm and dry year with many wildfires, the land may absorb less carbon dioxide than usual.

As the Earth warms further, climate scientists expect the land and the ocean to absorb a smaller share of carbon dioxide emissions, causing a larger share to end up in the air, said Doug McNeall, who studies these effects at Britain’s Met Office.

Xin Lan, the lead scientist responsible for NOAA’s global carbon dioxide measurements, referred to the natural absorption as a “carbon discount.”


“We pay attention to it because we don’t know at which point that this discount is gone,” she said.

In addition to carbon dioxide, the levels of other potent greenhouse gases like methane and nitrous oxide are also on the rise, which further contribute to warming.

An exceptional year

2023 was unusually hot, both on land and in the ocean. (The oceans absorb over 90 percent of the excess heat caused by global warming.) It was the hottest year in over 170 years of record keeping, even exceeding scientists’ predictions.

One contributing factor to 2023’s extreme heat was El Niño, a climate pattern that tends to raise global temperatures. During El Niño, warm ocean currents in the Pacific Ocean cause warmer and drier weather in the tropics. This can lead to droughts that slow the growth of trees and increase the risk of wildfires.

When this happens, the land tends to absorb less carbon dioxide, and more of it ends up in the air. Several climate scientists said this may be why last year’s rise in carbon dioxide levels was substantially higher than in the years preceding it.


Getting to zero

The current high emissions levels make the climate goal of limiting global warming to 1.5 degrees Celsius increasingly difficult to reach.

To limit warming to this threshold, experts say countries need to slam the brakes on global emissions and bring them down to near-zero in about a decade. And some are even considering more extreme technological solutions to help bridge the gap.

Even if global emissions were brought down to half of their current value, we would still continue to add carbon dioxide to the air, causing further warming.

“You need to bring them essentially down to zero in order to stop warming,” Mr. McNeall said.

How much more warming will occur depends on how long it takes for this to happen.


On one hand, clean energy investments are booming, and renewable energy production is rising globally. But energy demand is also projected to rise, coal power plants are still being built, and some sectors of the economy — like construction and manufacturing — are harder to decarbonize, making the task ahead a steep challenge.

Even if the world exceeds the 1.5-degree threshold, “every fraction of a degree matters,” Mr. McNeall said.

“The closer that you can get to that threshold, the better.”

About the data

NOAA’s annual global carbon dioxide measurements are an average of thousands of measurements made near sea level at about 30 locations around the world. To account for local differences in humidity, measurements are made using dry air.


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Taylor Swift's new album is rife with breakup songs. Psychologists explain why we love them



Taylor Swift's new album is rife with breakup songs. Psychologists explain why we love them

Perhaps never before have so many been so eager for something so steeped in heartbreak.

Taylor Swift‘s legions of devotees have eagerly anticipated her new album, “The Tortured Poets Department,” in hopes of gaining insight into her notoriously private six-year relationship with actor Joe Alwyn — particularly her perspective on its demise.

Swift delivers. In a track titled “Fresh Out the Slammer,” the 14-time Grammy Award winner sings of spending “Years of labor, locks and ceilings / In the shade of how he was feeling.” Another song called “So Long London” has her recounting that “I stopped CPR, after all it’s no use / Thе spirit was gone, we would never come to.”

“Songwriting is something that, like, actually gets me through my life, and I’ve never had an album where I needed songwriting more than I needed it on ‘Tortured Poets,’” Swift confessed to an audience in Melbourne, Australia, when her Eras tour played there in February.

Embracing a breakup album may seem like a macabre thing to do. But psychologists and cognitive scientists say songs about relationships gone bad actually can do listeners a lot of good.


“When people have a romantic breakup, they feel very alone in their experience,” said David Sbarra, a professor of psychology at the University of Arizona who studies how marital separation and divorce affect health. “They feel very isolated and think that the unique individual circumstances that characterized their breakup are particularly terrible.”

A breakup song can change that, said Sbarra, who conducted a deep dive into the emotional authenticity of Olivia Rodrigo‘s lyrics about a doomed relationship on her debut album “Sour.”

“Songs play a powerful role in normalizing our experience, in making us feel that we are not this weird, unusual, distorted kind of person,” he said.

Indeed, almost everyone who has reached their late teens has lived through the demise of a romantic relationship and endured the gamut of emotions that accompany it.

“The songs function to affirm their emotions, validate them, remind the listener they are not alone,” said Bill Thompson, a psychologist at Bond University in Queensland, Australia, who studies why music is important to people. “The emotions associated with breaking up are universal. They are a natural part of being human — even if they are also painful.”


Thompson said the concept of a love song — and by extension, a breakup song — may be written into our genes. Birds are known to serenade potential mates, while mice, humpback whales and other species use vocalizations to attract their partners.

“So among our ancestors, music might have played a role in mate selection and courtship,” he said. “It’s possible the prevalence of songs about love and courtship is a remnant of this ancestral function.”

The Sumerians of Mesopotamia devised a love song by around 2000 BCE, and scholars of Ancient Egypt have found love songs inscribed into pottery and written on sheets of papyrus. But it’s not clear when the first breakup song arose.

Why breakup songs caught on is less of a mystery, experts said.

“Breakups certainly inspire a rich broth of emotions,” said Arianna Galligher, a licensed clinical social worker and director of the Stress, Trauma and Resilience program at The Ohio State University Wexner Medical Center. “For a lot of people, listening to music helps them sort through their own emotional experience.”


Sometimes a breakup song can be cathartic. Here, Taylor Swift shows her strength during a performance at SoFi Stadium in Inglewood in August 2023.

(Allen J. Schaben / Los Angeles Times)

Sadness is often the primary emotion in a breakup song. But it’s certainly not the only one.

The 10-minute version of Swift’s “All Too Well” evokes a range of strong feelings, including “sadness at the end of the relationship, nostalgia about the past romance, regret that the relationship failed, anger at being dumped, resentment that the boyfriend moved on to other young women, scorn at his unfaithfulness, and fear of being hurt again,” Paul Thagard, a philosopher and cognitive scientist at the University of Waterloo, writes in his forthcoming book “Dreams, Jokes, and Songs.”


“I think it is a fabulous song,” Thagard said in an interview. “The reason it’s such a fabulous song is that it manages to convey a lot of different emotions.”

There’s no rule that says the emotions in a breakup song have to be negative. If a relationship was a poor fit — or even toxic — it’s appropriate to celebrate when it comes to an end, Galligher said.

Likewise, a breakup song suffused with sadness can resonate with a listener in a rock-solid relationship who is coping with another kind of loss.

“Sadness is not exclusive to breakups,” Galligher said. “Sometimes it can be helpful to listen to a song that is ostensibly about a breakup, but it helps you tap into something inside of you that knows sadness.”

She recalled a time that Adele’s “Someone Like You” came on the radio as she was driving to a memorial service.


“I was in a perfectly functional relationship, very happily coupled, and I found myself tapping into the song’s sadness and grief related to the loss of my friend,” she said. “It was really helpful to be able to access those emotions.”

When a breakup is fresh and the pain is raw, a song can serve as “a virtual empathetic friend” by affirming and validating a listener’s emotions, helping them process their feelings, and reminding them they’re not alone, Thompson said.

“The advantage is that you won’t get unwanted advice,” he said. “Music is just there for you and supportive.”

Thagard agreed: “There’s no judgment coming from a song.” (Unless you’re one of the unlucky men who has broken Swift’s heart.)

In addition, binging on breakup songs can be part of “a habituation process” that reduces the intensity of feelings associated with a romantic split, Sbarra said. Some people may find that necessary before they’re ready to talk about their breakup with another person.


“Sometimes folks need to spend a little time reflecting on their own feelings,” Galligher said. “Having a little bit of solitude to be introspective can be really beneficial, and then you seek the connection with others.”

Yet for all that breakup songs have to offer, it’s still possible to have too much of a good thing. Studies have found that listening to sad music can make sad people feel even sadder by prompting them them to dwell on their sadness.

“You do have to take your temperature about whether this is ultimately helping you or hurting you,” Sbarra said.

That said, listening to breakup songs can be a healthy way of distancing oneself from a painful event.

“It’s not you,” he said. “It’s Taylor Swift.”


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Opinion: The decline in American life expectancy harms more than our health



Opinion: The decline in American life expectancy harms more than our health

American life expectancy started dropping even before the pandemic. It’s a critical barometer of our nation’s health and a sign that all is not well in the U.S.

Much of the increase in preventable, premature death is attributable to drug overdose, which increased five-fold over the last couple decades. But this malaise is far broader, driven largely by growing chronic illness.

Rates of depression are reaching new highs. Obesity rates among adults have risen from 30% to 42% since the turn of the century, with severe obesity nearly doubling and driving up the risk of cardiovascular disease, diabetes and other serious health conditions. The return of vaccine-preventable illnesses has been a concern since the 2010s. Sexually transmitted infections have surged in the last decade. And for the first time since 1937, an infectious disease, COVID-19, became one of the top three causes of death in the country.

These health problems are alarming on their own. They also have a devastating impact on our economy. A one-year increase in life expectancy could boost economic output by 4%. On the other hand, as Americans’ health declines, our health expenditures continue to soar. As a country, we spend $4.5 trillion annually on health, representing 17% of GDP. Out-of-pocket healthcare costs have risen dramatically, straining workers’ finances and pushing people into bankruptcy. All this fuels a cycle of a sicker workforce and a weaker economy.


Policymakers acknowledged the link between the economy and public health at the height of the pandemic, providing federal relief programs such as cash assistance and paid sick leave designed to keep the nation’s workforce and economy as healthy as possible. But our abandonment of these efforts since getting COVID relatively under control sets our country up for mounting crises. We need to revive a historical source of support for public health measures: the business case for a healthy workforce.

In 1842, Edwin Chadwick argued in his landmark “Report on the Sanitary Conditions of the Labouring Population of Great Britian” that public health investments are crucial not only from a moral perspective, but also for economic productivity. Writing for the Atlantic in 1909, C.-E. A. Winslow, an American public health pioneer, wrote that employers who try welfare measures for workers “find that it pays.” And around that time, Wickliffe Rose, an American philanthropist, oversaw the Rockefeller Sanitary Commission to tackle hookworm disease as a controllable health problem, spurring economic productivity.

Hookworm, which can cause anemia and fatigue and impair development in children, was a significant problem in southern states in the late 1800s and early 1900s resulting from lack of access to clean water, poor sanitation and poor hygiene. Its symptoms were blamed on “laziness” — a stigma often attached today to symptoms of chronic illnesses, disabilities and mental health issues — and perpetuated cycles of poverty. Rose all-but-eradicated hookworm through education campaigns, expanding access to treatment and improving public sanitation.

Similarly, during World War II, the U.S. government invested in public health initiatives to curb the transmission of malaria in tropical and subtropical battlefronts; vaccinate against smallpox, typhoid fever and tetanus; and control sexually transmitted infections, which during World War I cost the U.S. Army more than 7 million workdays and 10,000 preventable discharges.

When it functions well, such public health infrastructure makes it easier for working people to lead healthy lives. The results have been dramatic, contributing in the last century to the average human lifespan doubling around the world.


Despite the impression given by COVID-19, public health has historically been about so much more than tracking disease outbreaks. It’s been about preventing disease. Access to healthcare and insurance play a role, but doctors and hospitals most often come into play after someone is already sick. Research shows that simple resources such as clean air and water, affordable healthy food, stable housing and safe workplaces are much better predictors of good health and longevity.

During the pandemic, programs addressing basic needs — eviction freezes, expanded food assistance and mandated paid sick and family leave for employees in smaller companies — enhanced housing stability, curbed COVID spread and protected Americans’ mental health. Since then, home affordability has plummeted; half of American renters spend more than 30% of their income on rent and utilities. In 2022, more than 40 million Americans lived in food-insecure households, adding to health issues in adults and children.

The U.S. is one of the only high-income nations that still lacks universal paid sick leave and family medical leave, forcing many people to go to work sick or risk losing a day’s wages. Interventions to improve workplace air quality, a vital component of a healthy workplace appreciated even by 19th and 20th century health reformers, have been overlooked.

The pandemic-era measures were dropped in part because of their cost. But what is much more expensive, and what is causing American workers needless suffering as our national health declines, is our current approach to health. Of our $4.5-trillion annual health spending in the U.S., the vast majority goes to treating people when they are already sick; only 4% supports programs to keep people and workers healthy in the first place. This focus on treating individuals after they have already fallen ill is much of the reason we pay dramatically more than other countries yet still have some of the worst health indicators in the world.

Once again treating public health as an economic imperative could help broaden support for the type of interventions that became polarizing during the pandemic — but have a long track record of improving wellbeing and productivity.


Céline Gounder (@CelineGounder), an infectious-disease physician and epidemiologist, is the senior fellow and editor-at-large for public health at KFF Health News. She is also the host of the podcast “Epidemic.” Craig Spencer (@Craig_A_Spencer) is an emergency medicine physician and professor of public health at Brown University.

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