Introduction

When I was in college, I worked as an evening receptionist for a local company. Each evening that I worked, I would take something with me to read to pass the time in between phone calls. In 2005, I had picked up a copy of National Geographic with a story inside about the keys to living a longer, healthier life. The ideas presented stuck with me, and I began to implement them in my own life and continued to research.

As I went on to become a Social Studies teacher, the information was not only relevant to the social sciences courses (like Psychology) that I was teaching, but was also of particular interest to many of my students. Especially, as it seemed, that life in American society does not necessarily support a healthy lifestyle. The most current research not only highlights our need to access quality, prevention focused healthcare, but also our need to access healthy food, ability to exercise, and our ability to reduce and react to stress.

Noticing that there is a disconnect between what our health needs are and the experiences that many Americans have in daily life, it seems clear that there is a need to request more of our governing institutions in terms of public policy that could support social structures that enable more Americans to practice healthy life styles. This unit plan is intended to focus on that intersection of topics by helping students to investigate the social structure around us, the impact that it has on our physical well-being, and what actions we can take to, in turn, impact the society around us.

Objectives and Rationale

I am hoping that through this lesson, my students will deepen their knowledge of the role of society in our lives and the role of each individual within a society. Our lifestyle choices will ultimately impact the “healthspan” that we enjoy throughout our lives, but it is also important to understand that some of the lifestyles choices that we make are the result of the society around us; the rules and norms that we follow, the ideas that are presented to us throughout our lives, and the social structures that we adhere to all have an impact on us, even, from current research by Nobel Prize Winner, Dr. Elizabeth Blackburn and Dr. Elissa Epel, down to a cellular level.

I hope that through our research that my students’ knowledge of varying societies and cultures is broadened beyond what we see in our city and to understand that what happens within our city has an impact on them as well. Throughout this unit, we will try to see the world from multiple perspectives and participate in the practice of examining data and utilizing it to help form our opinions. Through examination of our own country and others throughout the world, students will begin to develop their own opinions of how to address issues of public health.

And ultimately, I hope that students will be able to understand, not only the role of public policy in their lives, but to also more fully understand how they can impact the policies that exist around them. By utilizing Sterling Professor of Political Science at Yale, Dr. Ian Shapiro’s, research and knowledge that he shared with us in the Yale National Seminar on Public Policy in the United States, my students will have the opportunity to go beyond just thinking about the surface level of how policy is enacted through our government and examine the building blocks necessary to create change in a complex democratic system.

Through the connection of these different topics, I hope that students are able to create their own ideas and make their own plans for how to create change.

Background

The information provided in this section is intended to support knowledge around the current research on achieving optimal health, with a focus on both scientific and sociological research, this will allow students to see similarities in findings across fields. This information will be used to inform the policies that they would like to see enacted. The background information will then shift to policies and structures (from around the world and throughout the United States that impact our ability to participate in practices that support long and healthy lives) in order to provide students with the opportunity to develop their own ideas around policies that benefit public health. The final part of the background information will focus on analysis of how their ideas could make the journey to actual policy. The background in this section will focus on tools for analyzing the intricacies around the process of policy making. However, some prior knowledge from a Sociology course and the workings of the three branches of United States government will be essential to the process of this unit and a brief overview of sociology concepts will be provided in the Teacher Resources section of this unit.

The Science of a Long and Healthy Life

Science is enabling us to more fully understand what we need to do in order to live a longer and healthier life. In 2009, Dr. Elizabeth Blackburn (along with Carol W. Greider and Jack W. Szostak) were awarded the Nobel Prize in Physiology for their “discovery of how chromosomes are protected by telomeres and the enzyme telomerase.”¹ Since the award, Dr. Blackburn and Dr. Elissa Epel have published The Telomere Effect: Living Younger, Healthier, Longer. Although the title may suggest otherwise, the book is not intended to share the secrets of the fountain of youth. The work is actually intended to inform readers on how diet, lifestyle, and in particular, stress have an impact on the telomeres.

Telomeres, the base pairs of non-coding DNA that are compared to the ends of shoelaces throughout the book (this is because they protect our DNA from fraying, just like the caps on the end of our shoelaces in this analogy),² have been discovered to hold the key to extending the healthspan of humans and other species. The healthspan is defined as the years that an organism can live free of disease and this is the span of our lives that we would, naturally like to extend as long as possible. And the longer that we are able to expand this time, we are not only protected from major diseases, like cancer, diabetes, and heart disease, but also from more common germs (like, at the moment, protecting ourselves from the most severe COVID-19 symptoms).³

Every time that our cells divide, our telomeres shorten, eventually reaching a point where they are alive, but no longer dividing; at this point they reach a state called senescence.⁴ As newborn babies, we have approximately 10, 000 base pairs, by 35, we are down to around 7,500, and by 65 we are even further down to around 4,800. The death rate from chronic disease begins to increase at age 40 and goes up dramatically after age 60, with our inner biology reflecting our increased risk of disease.⁵

What Dr. Blackburn and Dr. Epel have found in their research is that we are able to slow the decrease of base pairs through different aspects of our lives that we are able to control (for the most part).  In some cases, we are even able to lengthen our telomeres with healthy choices.⁶

Throughout the book, Dr. Blackburn and Dr. Epel provide examples of research supported ways to improve diet, incorporate the right amount of exercise into our lives, to lessen the impact of stress on our physical selves, to develop supportive relationships, and to improve the environment around us.

In terms of diet, eating foods that reduce inflammation, lessen oxidative stress, and reduce insulin resistance. The recommendations in each of these categories strongly recommend an influx in varying plant based foods that help with each of these health needs.⁷

In terms of reducing stress, the researchers provide specific mindfulness, thinking patterns, and self-compassion techniques that help us to be more aware of the thought patterns that we have that can increase our stress, and in turn, shorten our telomeres. There is also a focus in the book to help us reduce stress by identifying and understanding the causes of our emotions and internal narratives.⁸

Humans, from our earliest times, have a need for a feeling of connection and support. In earlier times, that may have been the safety felt by the protection of a group, but even though our environment has become safer (there are less life threatening perils to be encountered on daily basis), we still have a need to feel that somebody supports us through the trials and tribulations of modern life. The feelings of support from friend or family relationships can decrease feelings of stress and increase the length of telomeres as well.

The book also focuses on the impact of the environment on our long-term health, with specific mentions of the effect of chemicals throughout our natural world, including the use of pesticides, the effects of deforestation and the prevalence of carbon throughout are air as result, and the impacts of toxic social stress, potentially from socio-economically disadvantaged neighborhoods, and the impact of toxic stress from the racism that is still prevalent within our society.⁹

The authors’ research has also shown that specific types of exercise have been shown to support telomere length. This includes two types of exercise: first, “moderate aerobic exercise, performed three times a week for forty-five minutes at a time,” and secondly, “high-intensity interval training (HIIT) in which short bursts of heart-pounding activity are alternated with periods of recovery.”¹⁰

Further studies on telomeres have shown that not only can they be increased, so can health outcomes as a result. In one study, a group of men over the age of 60 were found to be able to increase the length of their telomeres through a change in diet (to being more plant based), an increased practice in meditation and yoga, and regular participation in a therapy group compared to a control group that continued to live their lives without change to lifestyle practices.¹¹

Sociological Examination of habits that contribute to Long and Healthy Life

The Blue Zone Study conducted in the first years of the new millennia found that nine central tenants of long and healthy life characterized three geographic areas where people exhibited the longest life spans and least amount of early, middle age death (these original regions included Okinawa, Japan, Sardinia, Italy, and Loma Linda, California, and have been expanded to include Ikaria, Greece and Nicoya, Costa Rica). These groups were also freer from lifestyle related diseases.

The nine habits that each of these groups were found to have in common, included similar ideas around eating habits. First, most did not eat until reaching a feeling of “stuffed,” but rather followed what the study calls the 80% rule (only eating until you have filled 80% of your stomach). The diets of these groups also tend to lean towards being more plant based rather than heavy on animal based proteins. And finally, in the habits of eating category, it was found that many of the groups had a glass of wine with dinner (a glass—enough to consume the possible benefits of antioxidants found in wine that could protect from heart disease, but as alcohol can have harmful effects on the body, most definitely in moderation).¹²

Multiple other studies have supported the benefits of a more plant based and traditional diet, including a trial conducted at the University of Pittsburgh that showed an improvement in intestinal health when a group of African Americans switched from a processed, more meat heavy, western diet, to a more plant based, less processed and more traditional south African Diet.¹³

The Blue Zones study also identifies important components in feeling connected and having the right outlook on life and the contributions of these to long and healthy living. In terms of connection, these groups often put loved ones first, over other pursuits, have strong feelings of belonging within a loving and supportive network of friends, family or both. Furthermore, they are able to downshift, to find a way to calm down from the stresses of everyday life (this could mean a formal or informal practice of mindfulness, meditation, yoga, or some other simple way of reducing the feeling of stress). The people in these groups can also identify a sense of purpose for their life and existence.

And lastly, in terms of movement, these groups of people include regular forms of movement throughout each day of their life, whether that be walking, working, or simply getting up and down throughout the day. These not necessarily strenuous activities, aid in maintaining a healthy weight and keeping the body moving throughout a hopefully, long life.¹⁴

Health Around the World

Some students will undoubtedly focus on healthcare as they imagine a better, healthier United States and will enjoy comparing our system to those around the world.

It is important for me that students are able to conduct research to more fully form their understanding of cultures and societies around the world and how they function (sometimes with better health outcomes and benefits for their citizens). This will not only help to broaden their perspectives and knowledge, but also give them the chance to brainstorm about what is needed in our country.

We can see through World Health Organization rankings that we are falling in terms of healthcare rankings and life expectancy in comparison to our industrialized and developed peers around the world. The United States is currently ranked 37^th in an assessment of health systems, falling behind Western and Northern Europe and many other countries around the world.¹⁵

Despite spending the most on healthcare, we still are not able to compete with what other comparable countries are able to do and this drives Americans “deeper into poverty by lack of financial protection against ill-health” and that “the poor are treated with less respect, given less of a choice of service providers and offered lower-quality amenities.”.¹⁶

What can be done better in terms of health care coverage? France, currently ranked first in health care by the World Health Organization, insures its entire population through national statutory health insurance. They also have “controlled prices through strong-central oversight” which helps to ensure lower costs—thus despite the fact that a critique of French health insurance is that it leaves a lot to be paid by the individual, out of pocket costs are significantly lower.

Another important aspect of the French Healthcare system is that most immunizations and screening tests are paid for through the national statutory health insurance and the country has supported nationwide campaigns for people to access both of these essential practices.¹⁷

We can see a similar pattern with differing models and varying outcomes throughout the vast majority of our peer countries. These varying models provide a broad spectrum of potential solutions to improving healthcare in the United States.

We can also see that we fall below many of our peer countries in terms of happiness. Currently, we are ranked 19^th, again behind many of the Northern and Western European countries.¹⁸

It is important to note that when we look at rankings of happiness, we can begin to infer that possibly, this is in some way correlated to stress, which as mentioned earlier, can negatively impact our health.

Through an investigation of Finland and Denmark, who have been ranked first or second in happiness multiple times since the inception of the World Happiness Report in 2012, we can see, as Dr. Jeffery Sachs, a co-author of the report, that one contributor to happiness is a better balance between life and work. Life, in these countries, is not about gaining as much wealth as possible, but rather being able to work and enjoy life and family relationships.¹⁹

In the 1970’s the country of Bhutan innovated the idea of measuring happiness²⁰ and first presented this paradigm shift to the United Nations in 1998.²¹ Productivity and economic success have often been a measure of a country’s sport in the global hierarchy, but happiness has since become of interest include how one feels about their life is going, feelings of social support, the freedom to make life choices, and a healthy life expectancy.²²

Costa Rica, which ranked higher than the United States on the World Happiness report in 2020²³ has identified “high levels of spirituality, a strong cultural base and close social relationships” as reasons not only for longevity amongst its people, but also as contributing to its happiness.²⁴

Health in the United States

The ranking of the United States in terms of health and life expectancy has been falling in recent decades, especially in comparison to the rest of the developed world. This is reflective of many decades of policy and social structure that have contributed to poor health outcomes among many segments of the American population. When connecting back to the science and sociology of a healthy lifestyle, we can easily see that American life is not set up to support the practices that most contribute to a longer span of life filled with health of free of disease, and in turn, a longer life.

As the most obvious place to begin, we can look at access to quality and preventative healthcare. As a result of the Affordable Care Act (otherwise known as Obamacare), approximately 20 million more Americans became insured,²⁵ which leads the us to having approximately 91% of Americans with health insurance and about 10% without it. Uninsured Americans are precluded from accessing the necessary screenings that could help them prevent major diseases (especially those connected to lifestyle, like heart disease, certain cancers, and diabetes).²⁶ Uninsured Americans also contribute to increased cost with health insurance as a whole.²⁷

Despite having the most expensive healthcare in the world, our healthcare system is very “lean—with fewer physicians, hospital admissions, and other services than almost any country.”²⁸ As physicians (and nurses, who are facing and will continue to face a shortage over the next decade) are stretched thin, this impedes their ability to spend sufficient time with each patient and leads to burnout within the profession.²⁹  These challenges are also confounded by others, including, the extremely high cost of prescription drugs, a very complex healthcare system to navigate, and the process for how American physicians and hospitals are paid.³⁰ None of these factors can necessarily translate to better health outcomes for Americans.

Aside from the more obvious healthcare problems that we face as a nation, we also have many other factors that contribute to poorer health outcomes, however, we can begin to brainstorm policy suggestions that could improve our situation.

As documented earlier, in our everyday lives, we must have access to a healthy diet, exercise, and be able to destress—either through specific physical practices (like meditation, mindfulness, or yoga) or through the support of our friends and family. Unfortunately, our society does not always support these practices.

For instance, geography and access to transportation play a key role in access to healthy food, an inequality that not only favors health outcomes for wealthier individuals and families, but whole neighborhoods as well. Although food desserts exclude many urban (in particular, communities of color) and rural families from access to healthy foods, the American diet is highly processed and to compound the problem, these highly processed foods often are the most accessible and the cheapest, preventing 23.5 million Americans from making a healthy choice as of 2010.³¹

Beyond access to nutritional choices, our economic choices, in so many ways, can impact our health. As Arlie Russell Hochschild documented through interviews with citizens of Louisiana, large petrochemical companies have often exposed areas to hazardous chemicals, increasing personal exposure to harmful chemicals and their waste, destroying arable land and the ecosystem, and poisoning food sources, like seafood in the process. While interviewing Paul Ringo, a Louisiana resident and member of the non-profit environmental organization, Riverkeepers, he explained to Hochschild, “The Sabine River is a public river…but if you can’t drink in the river, and you can’t swim in the river, or baptize your young in the river, then it’s not your river. It’s the paper mill’s river,”³² highlighting the environmental and cultural impact that big industries have had on the health of the land and the American people.

General Russel Honoré, well known for leading the Joint Task Force and National Guard into New Orleans after Hurricane Katrina, explained to Hochschild that policies could be put in place to help places impacted by corporate pollution in the United States, like the area between Baton Rouge and New Orleans, known as “Cancer Alley.” He elaborates that the companies that profit from of these areas need to clean up after themselves (including a focus on polluted waterways and abandoned oil wells) and would benefit from monitoring devices that could help to understand the causes of environmental disasters.³³ These are potential policies that students can begin to investigate when thinking about how to help Americans become healthier. It might even be beneficial to continue to explore the impact of work on health, especially that of dangerous work that constantly exposes employees to harmful chemicals and other toxins and to explore the value that we place on profit and life.

Other types of economic inequality can also impact health. We have seen an increase in lower paying jobs and wage stagnation as unionized, production jobs left from the United States. As documented by the research of Anne Case and Angus Deaton, the stress of this change within our economy as a whole has led to an increase in death from opioids (followed by heroine and fentanyl), alcohol, and suicide have increased significantly amongst white Americans without a bachelor’s degree since the birth cohort year of 1950.³⁴ And although this research focused specifically on white Americans, as will be discussed further in this section, we have been aware for many years of the health impact of these issues, along with the stress of racism and prejudice on the African American community, as well as the Latino/a and Native American communities within our country.

The work of Dr. Nadine Burke Harris, the first (and current) Surgeon General of California, who practiced in medicine in the Bayview Area of California, has documented the impact of toxic stress on children and how those impacts can follow us into adulthood. While trying to find research that confirmed the impact of stress and adversity on physical wellness, Dr. Burke Harris came upon research that began to more fully explain this link. “…the National Council on the Developing Child as part of an ambitious effort to pull together the science of how early adversity affects the brains and bodies of children. The council, too, found that a dysregulated stress-response system was at the core of the problem.”³⁵ When the stress response system does not shut off, cortisol is able to run rampant through the body and can lead to a number of health concerns (as noted earlier when discussing Dr. Blackburn and Dr. Epel’s work—whose work is also referenced by Dr. Burke Harris in The Deepest Well).

In Dr. Burke Harris’s research, we see the effects of trauma at all levels of income, including the initial study that furthered her investigation in which participants were predominantly white from middle-income San Diego.³⁶ Dr. Burke Harris has also noted that while working in the Bayview Area, a neighborhood characterized by lower socio-economic status, that the presence of adults who could buffer the effects of toxic stress could help lessen the effects on children. She explained, “My day-to-day experience working in Bayview tells me that the struggles are real and ever present, but it also tells me that’s not the whole story. Bayview is the oily concrete you skin your knee on, but it’s also the flower growing between the cracks. Every day I see families and communities that lovingly support each other through the toughest of experiences imaginable. I see beautiful kids and doting parents.”³⁷

And although no socio-economic group is immune to the adverse effects of toxic stress and trauma, poverty does have an impact. As Dr. Burke Harris goes on to say, “But no matter how hard parents work for their kids, the lack of resources in the community is crushing.”³⁸ Other research has also shown that there is a gradient between income and health outcomes, with those at the very top having the best health outcomes overall.³⁹ As a result of her work, she has recommended that the ACE Test (Adverse Childhood Experience Test) should become a standard screening in every pediatrician’s office. In her practice, children who have experienced exposure to toxic stress and trauma as identified by the ACE screening are supported by a team of doctors, including therapists and counselors in order to treat the underlying health concerns that develop as a result,⁴⁰ showing that policy changes and more equitable distribution of resources could have lifelong positive impacts.

Although the health of Americans from all backgrounds can be impacted by the effects of stress, our history of racism and prejudice has added an even more significant burden upon African Americans, Latin Americans, and Indigenous Americans.

For instance, African American infants born to mothers with a college degree still die at a higher rate than white infants born to mothers without a high school diploma. Statistics like this show us that the effects of race in America have an extremely detrimental effect on health outcomes, possibly even more so than other socioeconomic factors. Dr. Amani Allen, a social epidemiologist, explains that an earlier “weathering” or an earlier decline in the health of African Americans can have a direct correlation to the marginalized status in American society that African Americans are forced to deal with on a regular basis throughout the life experience and is characterized by micro-aggressions, overt racism, and up to the police brutality that has recently sparked nationwide protest and includes prejudices within the medical field itself.⁴¹

To further highlight the impact of the toxic stress of racism and prejudice, research has also shown that newly arrived Latin American immigrants have less physical ailments than those who have lived in the United States for five years or more and that positive health outcomes can erode within a generation. This can possibly be attributed to the unhealthy diet that is prevalent in America, but may also be connected to dealing with the prejudice that is rampant in this country.⁴²

Indigenous Americans have also had a long history of social practices that have been detrimental to health outcomes and we have seen the negative health effects that have developed as a result displacement, loss of culture, and what many would describe as a genocide. For examples, in the Tohono O’Odham people, who live south of Phoenix, Arizona, half of the adult population has Type 2 Diabetes. Historically, the diet and way of life of the Tohono O’Odham and other Native American groups supported good health, but that way of life has been eradicated. Although many researchers looked to the genetics of specific populations, what they came to find was that all groups of people have the genetics to develop this disease. Although everybody has a risk of developing Type 2 Diabetes, it is seen in higher rates amongst Indigenous Americans, as well as African Americans and Pacific Islanders. All of these groups have suffered the loss of land, history, and culture. As a result, the economic and social structures that develop can contribute to the development of diseases, like Type 2 Diabetes.⁴³

Through any observation of American Society (historic or current), we can see that across many spectrums that the impact of our social and economic structure completely contradicts the finding of scientific and sociologic health researchers and leads to harm on health outcomes. It is a public health crisis of our own making, but because we have had a hand in its creation, we can also have a hand in its resolution.

How an idea becomes policy

As my students will shift from broadening their understanding of health outcomes to policy, it will be important for them to more fully understand the process of politics. For their final project in this unit, they will be asked to make a plan to create actual change, and it is one of my objectives that will be able to explain and understand the process and obstacles of creating policies that will help improve society.

Throughout the middle school and high school (and even elementary) experience, our students will begin to be exposed to the three branches of government and the process of bills becoming laws. Although this process is important to understand, it is equally important that students understand the intricacies of how public policy is formed. For an idea to actually become policy in a country, like the United States, the process is not quite as simple as the traditional School House Rock cartoon may suggest to our students.

It is important for them to understand how ideas for public policy can gain notoriety through influence of “dark money” in politics and the platform from which the wealthy and powerful are able amplify the ideas that will most benefit them. For instance, the Koch Brothers are able to funnel obscene amounts of money into political campaigns and to “educate” the American voter, but have also used their position to promote ideas like fighting government regulation as a matter of “justice.” This idea goes beyond promotion of an ideology, and is really an attempt to mold popular thought in a manner that benefits them financially.⁴⁴ The structure of our economy and society allows those like the Koch Brothers to amplify their voices over that of the masses without wealth and power.

For instance, Supreme Court Cases like Buckley v. Valeo that have narrowly defined corruption as “quid pro quo,” when somebody is able to donate to a campaign in exchange for a direct favor during governance and also equated money with speech, providing as Dr. Shapiro stated, a “megaphone” for some citizens.⁴⁵

While the importance of a small group of wealthy individuals should always be noted within American politics, another factor that students should understand in how we get public policy enacted are understanding the median voter theorem, the divide a dollar game, and the building blocks of coalitions as tools for analysis in understanding the philosophical aspects behind the more tangible aspects policy.

The Median Voter Theorem “predicts that democratic governments will tax the rich and redistribute the proceeds to the median voter.”⁴⁶ From a basic understanding of the mathematical principles of mean and median, we can begin to understand why politicians might focus on the median voter when looking to get elected. The average person economically (when including the wealthiest people at the top) skews much higher than reality. The median voter, looking at the exact middle of a population, is much “poorer than the average person”⁴⁷ and this accounts for most people in a capitalist system.⁴⁸

In following this line of thinking, it seems as though the majority of voters would support politicians who redistribute wealth from the top to the median voter and that politicians who do not do something about the experiences of the majority of voters risk losing their positions in the next election, but as we have seen throughout American History, voters do not always follow the median voter theorem.

To help illustrate the secondary factors that may motivate somebody’s voting decision, the “divide a dollar” game can help us (and students) to understand these influences and begin to understand how coalitions are built and their function within policy creation.

If three people were asked to divide a dollar, two could easily form a coalition to get more. For example, if the dollar was divided evenly, one third going to each, two of the three people could agree to split in evenly, increasing each of their shares to one half. But, the third could suggest a new coalition, giving one of the others the better half of a 60-40 split as this increases their share compared to either of the other scenarios—possibly receiving one third or nothing.

We can take this example further, by asking, why might these people choose to split the dollar in the ways that they are? Why might they attempt they attempt to get more money, are they only trying to get more for themselves or might they have more altruistic motives?⁴⁹

From this logical thought experiment, students can begin to examine how coalitions form and what they need to be successful. For instance, instead of focusing on the median voter as simply an individual, we begin to think of who the median voter may side with in a coalition and what other factors are at play for them. Politicians who are aware of this can compete for votes on factors other than just redistribution and the economics of the median voter, but also include concepts of morality, justice, and philosophical answers to the tangible problems that we face in modern society.⁵⁰

Beyond understanding why coalitions form, there are five other building blocks, including a moral narrative. Moral and ideological commitments can help to motivate people to do whatever is needed to be effective in organizing coalitions and holding them together.⁵¹ From understanding what motivates voters, organizations, and even the government as a whole, it is important to explore the narrative influencing voting and organizing.

To take the moral narrative to fruition in policy, coalitions must also focus on the next proximate goal. Although the coalition may disagree on some matters, the next proximate goal allows them to rally around a focal point and encourage political movement. Once a proximate goal is within reach, it is important for coalitions to think about how to retain the gains from the goals for long term. As our government can shift with each election, how can a policy survive the tumultuous waters of change? By entrenching these gains within the public and within policy, people will fight to keep what they have. As we can see through research on loss aversion, in general we do not want to lose what we have and will fight to keep these gains should someone try to take them away. If the gains of proximate goals are entrenched to multiple swaths of people, they have a higher chance of surviving political change.⁵²

When thinking about promoting and gaining support for a coalition and its ideas, resources, especially monetary resources are also a key component. It is an important factor to understand, how as stated previously, financial backing can amplify the voices of wealthy, those same wealthy individuals can use their resources to back some coalitions over others. A steady stream of financial support is often necessary, even when movement begins at the grassroots.⁵³

And finally, a strong leader is also essential to the success of a coalition. It is leaders who decide “how and where to deploy resources, they enlist allies for the cause; and the shape the moral narratives that promote and nurture coalitions to achieve proximate goals that are hard to reverse.” Without a strong leader, coalitions are not able to enact each of the other building blocks to effectively make change.⁵⁴

To examine these building blocks through application in actual policy, we can more closely examine healthcare coverage in the United States, as Dr. Ian Shapiro outlined in his Yale Lecture series on the historical and contemporary reasons that universal healthcare coverage has eluded the American healthcare system and what might become a possible option. First, we must ask ourselves why we don’t have universal healthcare coverage, like most of economic peers around the world.  It is important to note, that universal healthcare coverage is not a new concept around the world, with countries like the United Kingdom having made it policy shortly after World War II, while we still grapple with it today.

If look back through our history, small coalitions of private health insurance existed within the United States prior to World War II, but the economics of the World War II era, set the stage for employer based healthcare to become widespread throughout the country. In 1942, the federal government set wage controls, which prevented employers from raising wages. At the same time, there was a labor shortage leaving employers without a way to compete for labor. In 1943, the War Labor Board ruled that benefits (such as health insurance and contributions to pension funds) did not count as wages and thus allowed employers a route to attracting labor.

By the end of World War II, employer based healthcare plans had increased by 300% and were becoming an integral and expected part of employment in America. As mentioned earlier, most people are loss adverse, and don’t want to give something up that they already have.

Approximately two decades later in 1965, Lyndon B. Johnson’s administration would go on to establish Medicare for those over 65 years old. This was a major achievement, creating a universal healthcare program for the elderly.

This created two groups of people who were satisfied with their healthcare (those who had employer based healthcare and those over 65 who had Medicare) and thus split a potential coalition in the fight for universal healthcare. A very large swath of the American public did not feel the need to support any coalition to expand access to healthcare within the United States (and certainly not a universal program like those of other industrialized countries). In fact, those satisfied with their health insurance, may have even been averse to expansion, fearing not only the cost, but that the cost of expanded coverage would drain the pool of resources and hurt their own benefits.

As the coalition had been split, the many attempts by varying administrations to enact universal healthcare in the time since World War II have all failed to do so. When the Obama Administration gained control of both the White House and the Democratic Party gained control of both houses, the Obama Administration set to work to create legislation to expand healthcare coverage, a major campaign promise in the 2008 Presidential election.

Since World War II, the cost of healthcare in the United States had gone up dramatically. Medical inflation outpaced regular inflation by two to three times during this period. Cost had risen so much due to two important factors. The first factor was actually the lack of universal healthcare coverage. Without access to healthcare coverage, people who are sick or injured must resort to using the Emergency Room, the most expensive route to meeting medical needs. Without an ability to pay, that cost was passed on to everybody using the healthcare system, thus increasing prices overall. The second factor was an agreement that United States government could not negotiate drug prices with pharmaceutical companies as part of stipulations in Medicare Part D, a program created by the George W. Bush Administration that provided free prescription drugs to seniors. This caused a dramatic increase in the cost of healthcare coverage during the early years of the 21^st century.

Policy experts had recommended that to lower the costs of healthcare, the issues of drug costs would have to be dealt with first, followed by an expansion of coverage to more people. Both of these would help address both of the factors that had increased the cost of healthcare during the prior decades.

Unfortunately without a strong coalition to fight for the expansion of healthcare, the Obama faced an uphill battle against both the Pharmaceutical and Insurance Industries. Big Pharma did not want the United States Government to begin negotiating prices and cutting into their profits, while the insurance industry did not want to have to compete with a public option created by the government and both went to work lobbying for their own causes.

In order to get the Affordable Care Act passed into law, the Obama Administration ultimately gave up on the on the ability to negotiate drug prices with a more superficial option that really didn’t bring costs down very much.

Although in his 2010 State of the Union Address, President Obama would use strong language indicating his support of the public option, ultimately Senator Joe Lieberman, the 60h vote needed to pass the Affordable Care Act, would not agree to the bill unless the public option was taken out, which it was in order to get his support. Senator Lieberman noted that the public option could hurt the economic recovery that was happening at the time, cause prices to go up, or increase the national debt and that there were other ways to deal with corporations such as regulation and the court system. It is also important to note that Senator Lieberman received substantial political support from numerous insurance companies that exist within his state of Connecticut.

Once the bill was passed, it was challenged in Obama’s remaining first and second term and during the first year of the Trump Administration. First during a challenge within the court system, the Supreme Court made two rulings. The first that the penalty one must pay if they did not have insurance (the individual mandate) was considered a tax and therefore the federal government could enforce it. Secondly, as a method to increase state participation in the program the Affordable Care Act provided states with funds to expand and improve Medicaid if they agreed to implement the Affordable Care Act. Republican governors did not want to do so and therefore challenged that this was coercion by the federal government. The Supreme Court supported that this was not allowable by the federal government. And in 2017, the Trump Administration, supported by Republicans in the Senate, repealed the individual mandate as a tax during budget reconciliation.

Although the Affordable Care Act (otherwise known as Obamacare) was withered down through congressional policy and court decisions, it did expand coverage to 20 million Americans, which was an achievement. Unfortunately, there are still about 32 million uninsured Americans and 44 million underinsured Americans.

Since the coalition had been split, it has been impossible to create universal healthcare coverage within the United States. A new proposal has been posited in Dr. Ian Shapiro’s and Dr. Michael Gaetz’s book The Wolf at the Door to build a coalition and alleviate the shock of the cost of universal healthcare. These policy experts suggest expanding the pool of people who are able to buy into the Medicare system. Current policy allows people to keep their adult children on their insurance policies until their children reach 26 years of age. If this group of people, were permitted to buy into Medicare from age 26 to 30, they would be able to do so rather cheaply because of the general health associated with that age group. As this population continued to age, the upper age limit of those allowed to buy into Medicare could continue to increase (as this group of people would not want to give up their access to healthcare coverage).

As we look at this as a viable option to creating universal coverage over the course of a generation, we should also examine the changes in their employment prospects over the course of this age group’s life. While in prior historical periods, a large group of those satisfied with their healthcare coverage were those who had employer based healthcare coverage. But in changing times, many people will have to change jobs over the course of their working life, losing health insurance plans each time they switch jobs, or even professions (if switching a profession, the lapse in time of not having health insurance would definitely increase). This economic reality would decrease access to employer based healthcare coverage. Also, as costs continue to rise, employers are not able to offer comparable plans to those of the past, which also leads to a decrease in overall satisfaction with employer based plans.

As more and more young people become a part of this reality, this will begin to enable a coalition to form and lead to more people wanting to keep the new system that is slowly being established. It could also prevent the “sticker shock” of paying for a single switch from our current system to a universal healthcare system.⁵⁵

Teaching Strategies

To begin this unit students will participate in a jigsaw activity. The class will be divided into Group A and Group B. Group A will examine current research regarding scientific analysis of the practices and habits that we need to try to extend the healthy span of our life. This will mainly focus on the research on telomeres and the specific social, dietary, physical, and psychological practices that can improve our health as we grow and age. Group B will receive sociological research on those practices that researchers found to increase life expectancy and decrease middle age death in multiple populations around the globe. While in Group A and Group B students will read, discuss the research, and prepare to be an expert on their topic in pair made up of one student from Group A and one from Group B.

Hopefully students will not only further develop their knowledge of the healthy practices that both scientific and sociological research has found, but also see that there is a great deal of overlap, further supporting the efficacy of these practices in our everyday life.

Throughout the unit, students will consistently have to time to complete think-pair-share activities. Some of our topics throughout the unit will either be challenging due to their complexity, but also due to the heaviness of the topics as students are introduced them. It is for that reason that I want to give students the time to process their own thoughts and think and practice how to put those thoughts into words. By creating space to think and share with a partner, students will be more prepared to share their ideas with the whole group and further the collective thinking.

A practice that students will regularly participate during this unit and throughout their time in my classroom is small group research. When I ask students to examine other places around the world, I want them to individually discover what other countries’ cultures and policies look like. I hope that this will be guided by our discussions and their own curiosity about the world around them. Through small group research, students can have multiple experiences to develop their research abilities and prepare for post-secondary education. They will be asked to evaluate the sources and to create full pictures (not stereotyped tropes) about other places. Other opportunities for this practice could also occur as students engage in research to brainstorm policies that they would support and to whom they should turn to build coalitions and plan how to implement their policies.  Depending on the research resources at different schools, this may look different. Students may use computers or library resources.

An important aspect of the final project for student progress beyond the Social Studies classroom is the opportunity to write for a real audience. When planning a speech, a letter, a pamphlet, or an online resource, students will have to think about who will read their work and what are the ways to best express their opinions in order to truly gain support.

Classroom Activities

The larger intention of this unit is to allow students to think creatively about policy, how policy is created, and how we can improve the lives of the people in our city, our country, and around the world. It is my hope that not only will students begin to understand how we can make systems that allow us to be healthier and happier, but that they can further understanding developing an expertise and skills to really make changes happen. The unit will go through three phases, first students will examine what the research says about being healthy. This will involve a look at what policies and practices exist in our country and around the world, including, but not limited to healthcare. This will give students the opportunity to brainstorm what they would like to see happen. Once have they have done that, they will examine potential policies within the United States that could improve public health. And then as they begin to prepare for creating and planning action steps for their own policy, they will examine various analytical tools to really investigate what goes into making policy. Each lesson detailed here plays a significant role in each phase of the unit.

Activity: Sociology and Science Meet

In the first activity of this unit, students will divide into two groups. Group A will receive resources regarding the science behind a long and healthy life. They will read, discuss, and prepare to share with a partner the current research on telomeres and the habits that support health at the cellular level. Group B will receive sociological research regarding the habits that those populations with longest lived populations practice a daily basis around the world. Group B will also prepare to share with a partner from Group A.

Once each group is ready, they will partner up with somebody from the opposite group and compare and contrast the research of the scientists and the research of the sociologists. It will hopefully be apparent to the students that both of these groups reported similar findings, despite participating in different methods of research. They will also hopefully be able to build on each other’s knowledge to develop a fairly in-depth knowledge of what we can each do to live a healthier life.

Following this activity, students will begin a brainstorming period to begin to answer the question, how do we support healthy lives. They will have to opportunity to discuss with peers and research cultural practices and policy around the world that contribute to higher rates of health and happiness. This may include access to preventative healthcare coverage, but we will be open to creative takes on helping people achieve health through other types of policy as well.

Activity 2: How policy can impact health for the better

Through examination of Dr. Nadine Burke Harris’s work and screening recommendations students will be able to examine how wide scale implementation of a policy could improve health in children

During this activity, students will read excerpts from Dr. Nadine Burke Harris’s book The Deepest Well: Healing the Long-Term Effects of Childhood Trauma to better understand how stress can negatively impact our health and how doctors can use a quick set of questions to help screen for these negative impacts in children. Through Dr. Burke Harris’s work, research, and advocacy for a universal screening of childhood trauma, children can be better supported to achieve long term health, both physically and mentally. Students will use a think-pair-share to read the excerpts independently and track their reactions through annotation, share their ideas with a partner, and then share in a whole class discussion about their thoughts on how small (and cost effective) changes can improve overall health.

Students will take this opportunity to re-examine the ideas that they developed during the initial brainstorming period and think about how to refine their ideas and how they could actually be implemented.

As part of this activity, in small groups, we will begin to analyze current data around public health within the United States, specifically referencing the information on health in the United States and the factors that impact it across various sectors of the American Public.

It is important for students to begin having real conversations about how bias, prejudice, and inequality create health inequality, in addition to economic inequality. Students should begin to and continue to raise their awareness of inequality within our society during this activity and throughout the unit.

Analytical Tools and coalition building

During this activity, students will have the opportunity to experiment with a series of analytical tools and coalition building. The activities will be based on thought experiments presented in the Yale National Seminar on Public Policy with Dr. Ian Shapiro and scaffolded for the high school classroom.

First students will participate in a physical representation of the “divide a dollar game.” Students will work in groups of three. Each group will be given an envelope with various coins that add up to one dollar.⁵⁶ They will also have a set of questions to prompt their discussion. This question set will include questions like, “What is the most even way to divide the dollar between three people?”, “Is there a way for two people to get more of the dollar?”. “What could the third person do in response?”, and “Would the use of the money change who should get more?”.

We will then engage in a class discussion about each of these questions, giving students the opportunity to share their thoughts on the activity and its application to the real world. As the discussion progresses, students will turn towards how this “game” may play out in the political arena and in political thought across the country.

Next, students will participate in a hypothetical situation in which they will analyze their own perspective on loss aversion also presented in the Yale National Seminar lead by Dr. Shapiro. The students will be presented with two scenarios. In one, a person is told that they are the winner of a two million dollar lottery. The next day, the person finds out that, actually, there was another winning ticket and the winning amount will have to be split between two people, meaning they only won one million dollars. In a second scenario, a person is told that possess one of two winning tickets for a one million dollar lottery and they will receive five hundred thousand dollars. The next day, they are notified that there was only one winning lottery ticket, so they actually won one million dollars. Students will explain who is happier.⁵⁷

Once they have explained who is happier and why, they will begin to discuss in pairs how this may play out in real life and politics. They will have a question set that includes more personal questions, like, “how may this apply to your own life?” and “have there been any situations in which you have felt that you didn’t want to lose something?” and a more political question set that includes questions like, “how might a politician use this principal to frame their campaign?” and “how might this principal affect if a policy is put into place?” or “how might this impact a policy that some politicians want to get rid of?”

Finally, students will be introduced to both the median voter theorem and the building blocks of coalition building through a short power point presentation. Throughout the presentation, students will be introduced to the reason that the United States does not have universal healthcare coverage and a possible solution for expanding coverage to more people. This will serve a model for how to examine how a policy may become a reality, how is politics involved, and adding more layers onto the traditional lessons of how a bill becomes a law. The thought experiments presented earlier in the lesson will begin to be applied as well.

Students will then participate in a practice scenario in applying these concepts to a hypothetical school policy. They will have the opportunity to begin to apply this knowledge on a small scale in order to prepare for the larger final unit project that will come in the following weeks.

Teacher Resources

If planning on discussing sociological theories as part of the unit, each of the three theories mentioned in the American Sociological Association Standards for High School Sociology are described in brief detail here.

Functionalist Perspective

The functionalist perspective explains that each part of a society has a specific role to fulfill. Emile Durkheim compared society to a living organism, like a cell, in which each part functions to make a working whole. For many parts of the society, an institution has formed to aid in the completion of necessary tasks. If an institution fails to meet the needs of the society then it will fade with time, as with all unnecessary parts of society. Italian philosopher, Antonio Gramsci, critiqued this perspective as simply a way to support the maintenance of the status quo.⁶¹ Although I am citing a short article from the ThoughtCo website that gives a good foundational summary of this perspective, Khan Academy also has a quick video that can be helpful for students as well.

Conflict Theory

Heavily based on the works of Karl Marx, Conflict Theory, as its name suggests, states that social tension arises when “resources, status, and power are unevenly distributed between groups in society and that these conflicts become the engine for social change.”

Many theorists have built on Marx’s conflict theory, including Antonio Gramsci, who explained that ideologies must be overcome and more work would be needed to overcome cultural hegemony, while Max Horkheimer, and Theodor Adorno focused on the rise of mass culture and how mass production, music, and media have helped to maintain cultural hegemony. Feminist theory, critical race theory, postmodern and postcolonial theory, queer theory, post-structural theory, and theories of globalization and world systems have also been drawn to conflict theory, as well as C. Wright Mills who described a “tiny, power elite” who ruled America from the mid-20^th century.⁶²  Again, Khan Academy also has a good, short video to help explains the foundations of conflict theory.

Symbolic Interaction

Unlike the Functionalist perspective and Conflict Theory that focus on large, grand schematics of society, Social Interaction focuses on the individual interactions that happen on a daily basis. “The central principle of the interactionist perspective is that the meaning we derive from and attribute to the world around us is a social construction produced by everyday social interaction.” The theory begins in the work of Max Weber, but is built upon by George Herbert Mead and Herbert Blumer.⁶³

According to this theory, people do not form meaning based solely on what they observe, but also on subjective beliefs, “thus, society is thought to be socially constructed through human interpretation.” Critics of this theory highlight that by focusing on such an individual level that the grand scheme is missed.⁶⁴

Other Thinkers and Writings

Throughout this unit many other sociologists, philosophers, and researchers of all kinds can help students further analyze why our society is structured in the way that it is, how we allow inequalities to exist, and to further think about how we create change.

For example, the field work and sociological research of W.E.B. DuBois is also foundational to the study of sociology and critical to early understanding of the psychological effects of racism. The critical thought of bell hooks and her contributions to critical race theory and feminist theory can also help students to further their critiques of modern society and the effects that it has on individuals.

Appendix on Implementing District Standards

I plan on using this unit in two different courses. In the Sociology Class that I teach, we will focus more on the global policies and habits that support healthy populations and how institutions and society play a large role in individual life. I will also use the lesson in my Civics class, during which we will make very clear connections between earlier lessons on the three branches of government and the more nuanced and sophisticated that I got to experience in Dr. Shapiro’s seminar. This will help to support students understanding of how our government works. While discussing the implementation of standards, I will reference the National Council for the Social Studies Standards, The American Sociological Association Standards for High School Sociology, and Pennsylvania Standards, where applicable.

National Council for the Social Studies-Civic Ideals and Practices

“An understanding of civic ideals and practices is critical to full participation in society and is an essential component of education for citizenship, which is the central purpose of social studies. All people have a stake in examining civic ideals and practices across time and in different societies. Through an understanding of both ideals and practices, it becomes possible to identify gaps between them, and study efforts to close the gaps in our democratic republic and worldwide.

Learning how to apply civic ideals as part of citizen action is essential to the exercise of democratic freedoms and the pursuit of the common good. Through social studies programs, students acquire a historical and contemporary understanding of the basic freedoms and rights of citizens in a democracy, and learn about the institutions and practices that support and protect these freedoms and rights, as well as the important historical documents that articulate them. Students also need to become familiar with civic ideals and practices in countries other than our democratic republic.”⁵⁸

We will meet this standard in the Civics classroom through the discussion of the policies regarding healthcare in multiple countries and the politics of healthcare within the United States. We will apply knowledge of how each branch of government works. Students will also have the ability to put these practices into action as they make their own plans for policy.

Pennsylvania Academic Standards for Civics and Government⁵⁹

Specific to Pennsylvania we will address standards 5.3.9. A (Explain the structure, organization, and operation of the local, state, and national government including domestic and national policy-making) and 5.3.9. B (Compare the responsibilities and powers of the three branches within the national government, while focusing on 5.3.9.C (Explain how bill becomes a law on a federal, state, and local level).

The American Sociological Society National Standards for High School Sociology⁶⁰ can also be addressed for Sociology Standards. As noted in these standards, we will address the role of institutions in our lives and how we can impact those institutions, as well as an examination of power structures and privilege.

Bibliography

“American Sociological Association National Standards for High School Sociology.” American Sociological Association, September 2015. https://www.asanet.org/sites/default/files/savvy/DOCS-%2379445-v1-ASA_National_Standards_for_HS_Soc_-_Pre-publication_version(1).pdf. This website provides National Standards for the teaching of High School Sociology. As many states do not have a specific set of Sociology standards, it is very useful when planning Sociology lessons and units.

Anne Case and Angus Deaton Discuss the Depths of Despair. Center for the Economics of Human Development, 2020. https://cehd.uchicago.edu/?p=2796. Anne Case and Angus Deaton discuss the declining health outcomes for white Americans without a college degree.

Blackburn, Elizabeth H., and Elissa Epel. The Telomere Effect: A Revolutionary Approach to Living Younger, Healthier, Longer. New York: Grand Central Publishing, 2018. This book contains a very detailed description of what the body needs to support long-term health and wellness and contains very understandable language regarding higher level scientific concepts.

Buettner, Dan. “Reverse Engineering Longevity.” Blue Zones, June 5, 2020. https://www.bluezones.com/. This website details the results from the well-known, earlier study that highlights nine principles of healthy living. By examining the habits of the longest-lived people, researchers have identified what practices are the most essential to our health and repeat across cultures.

Coghlan, Andy. “Healthy Living Can Turn Our Cells' Clock Back.” New Scientist, September 17, 2013. https://www.newscientist.com/article/1989324-healthy-living-can-turn-our-cells-clock-back/. This article details a research study in which a group of men above sixty years old were able to lengthen telomeres through meditation, yoga, diet, and group therapy.

Cole, Nicki Lisa. “Social Theory and the Rich Kids of Instagram.” ThoughtCo, October 6, 2019. https://www.thoughtco.com/symbolic-interaction-theory-p2-3026645. A short, student friendly introduction to Symbolic Interaction.

Crossman, Ashley. “Everything You Need to Know About Functionalist Theory.” ThoughtCo, January 24, 2020. https://www.thoughtco.com/functionalist-perspective-3026625. A short, student friendly, and informative introduction to the Functionalist Perspective.

Crossman, Ashley. “Understanding Conflict Theory.” ThoughtCo, July 3, 2019. https://www.thoughtco.com/conflict-theory-3026622. A short, student friendly, and informative introduction to Conflict Theory.

Crossman, Ashley. “What Is Symbolic Interactionism?” ThoughtCo, January 30, 2020. https://www.thoughtco.com/symbolic-interaction-theory-3026633. A short, student friendly, and informative introduction to Symbolic Interaction.

Dahl, Robert A., and Ian Shapiro. ON DEMOCRACY. Place of publication not identified: YALE UNIV Press, 2021. Contains chapters detailing the influence of money in politics and the Supreme Court decisions that have lead us to where we are today.

Emanuel, Ezekiel J. Which Country Has the World's Best Health Care? New York: PublicAffairs, 2020. Newly released book detailing the best healthcare systems in the world, chapters are organized by country and contain important data points, like cost, access to preventative medicine, and challenges that the country faces with their system in the coming years.

Fendt, Lindsey. “Why Costa Rica Is One of the Happiest Countries In The World.” HuffPost. HuffPost, September 6, 2018. https://www.huffpost.com/entry/costa-rica-happiness-well-being_n_5b6184a8e4b0de86f49c7611. Article detailing why Costa Ricans rank so highly on the World Happiness Report.

Graetz, Michael J., and Ian Shapiro. The Wolf at the Door: The Menace of Economic Insecurity and How to Fight It. Cambridge, MA: Harvard University Press, 2020. In particular, Chapter 2 eloquently elaborates on the factors that influence public policy within the United States and highlights methods of thinking about complex topics in a hypothetical way.

Halliwell, John F., Richard Layard, Jeffrey D. Sachs, Jan-Emmanuel De Neve, Lara B. Aknin, Haifang Huang, and Shun Wang, eds. Publication. World Happiness Report 2020, 2020. https://happiness-report.s3.amazonaws.com/2020/WHR20.pdf. Report detailing happiness rankings by country and descriptions of the process and data used in compiling the report.

Harris, Nadine Burke. The Deepest Well: Healing the Long-Term Effects of Childhood Adversity. Boston, MA: Houghton Mifflin Harcourt, 2018. Dr. Nadine Burke Harris details her experience practicing pediatric medicine in the Bayview Area of California, her realizations about childhood trauma and health, and how we can improve long-term health beginning in childhood.

Hochschild, Arlie Russell. Strangers in Their Own Land: Anger and Mourning on the American Right. New York: The New Press, 2016. Academic Arlie Russell Hochschild details her experiences interviewing and getting to know voters in poverty-stricken and environmentally hurt areas of Louisiana to better understand their voting patterns and perspective.

“International Diet Swap Shows Effects of Diet on Colon Cancer Risk.” UPMC, August 6, 2015. https://www.upmc.com/media/news/diet-swap. UPMC Medical researchers swapped diets between South Africans and African Americans finding the Western/American diet had a significant, negative, and rapid impact on those eating a traditional South African diet. The study also found that those who switched to a traditional South African diet reaped benefits fairly quickly as well.

Lecture 25: Tough Nuts--Education and Health Insurance, 2019. https://www.youtube.com/watch?v=kqm8T_FNnog. Part 25 Dr. Ian Shapiro’s Public Policy Lecture series published by Yale University.

Levine, Susan, Erin Malone, Akaki Lekiachvili, and Peter Briss. “Health Care Industry Insights: Why the Use of Preventive Services Is Still Low.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, March 14, 2019. https://www.cdc.gov/pcd/issues/2019/18_0625.htm.

Mayer, Jane. Dark Money: The Hidden History of the Billionaires behind the Rise of the Radical Right. New York: Doubleday, 2017. An extensive dive into the sometimes unseen role of money and those who have in the politics of the far right, highlighting the connection between billionaires and those with much less.

McCarthy, Julie. “The Birthplace Of 'Gross National Happiness' Is Growing A Bit Cynical.” NPR. NPR, February 12, 2018. https://www.npr.org/sections/parallels/2018/02/12/584481047/the-birthplace-of-gross-national-happiness-is-growing-a-bit-cynical. Description of Bhutan’s initial work to rank countries on factors other than economic productivity and power, but also describes some changes to the populations feelings over the last few years.

“National Curriculum Standards for Social Studies: Chapter 2-The Themes of Social Studies.” National Council for the Social Studies. Accessed August 1, 2020. https://www.socialstudies.org/national-curriculum-standards-social-studies-chapter-2-themes-social-studies. NCSS standards for high school Social Studies; the theme of Civics and Government was highlighted in this Unit.

“The Nobel Prize in Physiology or Medicine 2009.” NobelPrize.org, October 5, 2009. https://www.nobelprize.org/prizes/medicine/2009/press-release/.

Nova, Annie. “How the Affordable Care Act Transformed Our Health-Care System.” CNBC. CNBC, December 29, 2019. https://www.cnbc.com/2019/12/29/how-the-affordable-care-act-transformed-the-us-health-care-system.html. Description of the impact of the Affordable Care Act approximately 10 years following its implementation.

“Pennsylvania Academic Standards for Civics and Government.” Pennsylvania Department of Education, July 18, 2002. https://www.stateboard.education.pa.gov/Documents/Regulations%20and%20Statements/State%20Academic%20Standards/CIVICSANDGOVERNMENT.pdf. The PA Department of Education’s Standards for Civics and Government.

Racism's Impact on Lifespan and Health. Chataqua Institution, 2020. https://www.youtube.com/watch?v=2GbDAq5cuhA. Recording of a lecture given by Dr. Amani Allen regarding the impact of racism on the health of African Americans.

Stieg, Cory. Why Finland and Denmark Are Happier Than The U.S. CNBC Make It. CNBC, 2020. https://www.cnbc.com/2020/01/09/are-danish-people-really-happy-nordic-work-life-balance-secrets.html. This approximately 25 minute video contains experts who worked to complete the World Happiness Report and citizens of Finland and Denmark explaining why those two countries are continually reported to be the happiest countries in the world.

Tander, Ajay, Christopher JL Murray, Jeremy A Lauer, and David B Evans. Publication. Measuring Overall Health System Performance From 191 Countries 30. Vol. 30. GPE Discussion Paper Series. World Health Organization, n.d. Ranking and description of the ranking process of World Health systems.

Treuhaft, Sarah, and Allison Karpyn. Rep. The Grocery Gap: Who Has Access to Healthy Food and Why It Matters. Policy Link & The Food Trust, 2010. Description of the food desserts that afflict rural and urban (particularly communities of color) and what the consequences of this geographic challenge.

Unnatural Causes: Is Inequality Making Us Sick. California Newsreel - UNNATURAL CAUSES, 2014. http://newsreel.org/video/UNNATURAL-CAUSES. This multi-part documentary is available for rent through the listed website. Episodes 1, 2, and 4 were used. Each episode delves into health within a group of Americans, including African Americans, Latino/a Americans, and Native Americans, as well as health impacts due to socio-economic status.

“World Health Organization Assesses the World's Health Systems.” World Health Organization. World Health Organization, July 29, 2013. https://www.who.int/whr/2000/media_centre/press_release/en/. Description of the impact of poverty in the United States and around the world on the ability to access quality healthcare.

Notes

¹ “The Nobel Prize in Physiology or Medicine 2009.”

² Blackburn and Epel, The Telomere Effect, 6.

³ Blackburn and Epel, The Telomere Effect, 3.

⁴ Blackburn and Epel, The Telomere Effect, 10.

⁵ Blackburn and Epel, The Telomere Effect, 11.

⁶ Blackburn and Epel, The Telomere Effect, 12-13.

⁷ Blackburn and Epel, The Telomere Effect, 224-239.

⁸ Blackburn and Epel, The Telomere Effect, 100-126.

⁹ Blackburn and Epel, The Telomere Effect, 255-279.

¹⁰ Blackburn and Epel, The Telomere Effect, 178.

¹¹ Coghlan, “Healthy Living Can Turn Our Cells' Clock Back.”

¹² Buettner, “Reverse Engineering Longevity.”

¹³ “International Diet Swap Shows Effects of Diet on Colon Cancer Risk”

¹⁴ Buettner, “Reverse Engineering Longevity.”

¹⁵ Tander et al., “Measuring Overall Health System Performance From 191 Countries.”

¹⁶ “World Health Organization Assesses the World's Health Systems.”

¹⁷ Emanuel, Which Country Has the World's Best Health Care?

¹⁸ Halliwell et al., eds., “World Happiness Report 2020.”

¹⁹ “Why Finland and Denmark are the happiest countries in the world.”

²⁰ “Why Finland and Denmark are the happiest countries in the world.”

²¹ McCarthy, “The Birthplace Of 'Gross National Happiness' Is Growing A Bit Cynical.”

²² “Why Finland and Denmark are the happiest countries in the world.”

²³ Halliwell et al., eds., “World Happiness Report 2020.”

²⁴ Fendt, “Why Costa Rica Is One of the Happiest Countries In The World.”

²⁵ Nova, “How the Affordable Care Act Transformed Our Health-Care System.”

²⁶ Levine et al., “Health Care Industry Insights: Why the Use of Preventive Services Is Still Low.”

²⁷ Emanuel, Which Country Has the World's Best Health Care?, 52.

²⁸ Emanuel, Which Country Has the World's Best Health Care?, 50.

²⁹ Emanuel, Which Country Has the World's Best Health Care?, 53.

³⁰ Emanuel, Which Country Has the World's Best Health Care?, 52-54.

³¹ Treuhaft and Karpyn, “The Grocery Gap: Who Has Access to Healthy Food and Why It Matters”

³² Russell Hochschild, Strangers in Their Own Land, 50.

³³ Russell Hochschild, Strangers in Their Own Land, 61-62.

³⁴ Case and Deaton, Anne Case and Angus Deaton Discuss the Depths of Dispair, Center for the Economics.

³⁵ Burke Harris, The Deepest Well,

³⁶ Burke Harris, The Deepest Well, 38-39.

³⁷ Burke Harris, The Deepest Well, 9-10.

³⁸ Burke Harris, The Deepest Well,

³⁹ Llewellyn, Unnatural Causes, Episode 1.

⁴⁰ Burke Harris, The Deepest Well, 100-115.

⁴¹ Allen, Racism's Impact on Lifespan and Health.

⁴² Garcia Rios and Rodriguez, Unnatural Causes, Episode 2.

⁴³ Fortier (Metis-Ojibway), Unnatural Causes, Episode 4.

⁴⁴ Jane Mayer, Dark Money, 123.

⁴⁵ Dahl and Shapiro, ON DEMOCRACY, 202-203.

⁴⁶ Graetz and Shapiro, The Wolf at the Door, 39.

⁴⁷ Graetz and Shapiro, The Wolf at the Door, 37.

⁴⁸ Graetz and Shapiro, The Wolf at the Door, 37.

⁴⁹ Graetz and Shapiro, The Wolf at the Door, 40-41.

⁵⁰ Graetz and Shapiro, The Wolf at the Door, 42.

⁵¹ Graetz and Shapiro, The Wolf at the Door,

⁵² Graetz and Shapiro, The Wolf at the Door, 49-53.

⁵³ Graetz and Shapiro, The Wolf at the Door, 58-60.

⁵⁴ Graetz and Shapiro, The Wolf at the Door, 60-63.

⁵⁵ Shapiro, Lecture 25: Tough Nuts—Education and Health Insurance.

⁵⁶ Graetz and Shapiro, The Wolf at the Door, 40-41.

⁵⁷ Situation presented in readings and lecture of YNI Public Policy Seminar lead by Dr. Ian Shapiro.

⁵⁸ National Council for the Social Studies Standards.

⁵⁹ Pennsylvania Academic Standards for Civics and Government.

⁶⁰ American Sociological Society National Standards for High School Sociology.

⁶¹ Crossman, “Everything You Need to Know About Functionalist Theory.”

⁶² Crossman, “What Is Conflict Theory?”.

⁶³ Cole, “Social Theory and the Rich Kids of Instagram.”

⁶⁴ Crossman, “What Is Symbolic Interactionism?”.