Revolutionizing Research and Treatments for Infection-Associated Chronic Diseases

The National Institutes of Health should create an Office of Infection-Associated Chronic Illness Research. Reporting directly to the NIH Director, the Office would provide a timely and urgently needed command center for prioritizing innovative research across a group of complex, chronic conditions that are all known to be downstream effects of viral and bacterial infections. These include Long Covid and many others. The Office of IACIR should champion transformative, catalytic research that cuts across multiple institutes and centers.

The Covid-19 pandemic has proven to be a massive disabling event that has shined a bright and historic light on infection-associated illnesses. As many as 1 in 5 adults develops a new health condition in the aftermath of Covid, and for many, the condition could be lifelong. This should not come as a surprise. For decades, millions of sufferers have experienced debilitating illness, gaslighting, misunderstanding, lack of insurance coverage, disability, and no FDA-approved treatment options. In alignment with President Biden’s National Research Action Plan for Long Covid, the Office should pursue a two-pronged approach that includes pioneering next-generation diagnostics while also fast-tracking patient-centered clinical trials for repurposed drugs. The Office would spur creation of a world in which all people with an infection-associated chronic illness have access to a timely diagnosis and effective treatments.

Challenge and Opportunity

The world faces a massive problem with long term disability due to the long-term effects of infections. The cost of Long Covid is estimated at $3.7 trillion over five years, according to Harvard University economist David Cutler. Within the United States, it is estimated that up to 23 million Americans currently have or have had Long Covid or similar complex, chronic conditions.

Long Covid is part of a family of infection-associated chronic illnesses. More than two-thirds of people with Long Covid develop moderate to severe dysautonomia, most commonly presenting as postural orthostatic tachycardia syndrome (POTS), a condition estimated to impact up to 3 million Americans prior to the pandemic. Dysautonomia symptoms, the result of a problem with the autonomic nervous system, include lightheadedness, palpitations, profound fatigue, exercise intolerance, cognitive impairment, gastrointestinal dysmotility and more. Similarly, about half of all Long Covid cases fit the criteria for myalgic encephalomyelitis, or chronic fatigue syndrome (ME/CFS). With two of the most common symptoms of ME/CFS being unrelenting exhaustion and brain fog. These symptoms are also seen in persistent Lyme disease. Patients with Long COVID, dysautonomia/POTS, ME/CFS or persistent Lyme disease often present with autoimmunity, small fiber neuropathy, gut dysbiosis, migraine, mast-cell activation syndrome (MCAS), Ehlers Danlos syndrome (EDS), and cranio-cervical instability (CCI).

While there appears to be significant shared pathophysiology and symptomatology between these diseases, progress in each of these diseases has been stymied because research has been siloed and underfunded. For instance, one analysis of NIH funding and disease burden showed that ME/CFS received just 7% of research dollars commensurate with disease burden, making it the most underfunded disease at NIH with known disability-adjusted life years data. Reaching parity with diseases of similar severity and prevalence would require a fourteen fold increase in ME/CFS.

Each condition is in its own silo for a different reason, making full coordination impossible until a new NIH office is established. For instance, Gulf War illness doesn’t have an NIH budget line item at all; it is studied through the Department of Defense’s medical research program. And while the NIH studies acute Lyme infections, the agency didn’t formally start studying “post-treatment Lyme disease syndrome” until 2023. For POTS, there is a lack of research showing quality of life disruptions for dysautonomia sufferers. This makes it impossible to quantify the gap in research funding given the disorder’s large economic burden. And for decades, ME/CFS research was hamstrung in part because it was housed in NIH’s poorly funded Office of Research on Women’s Health. In short, to adapt a line from Leo Tolstoy’s Anna Karenina, “Understood diseases are all alike; every misunderstood disease is misunderstood in its own way.”

Therefore, studying infection-related conditions all together, within one multidisciplinary NIH office, provides an unprecedented scientific opportunity to build on existing research and apply a comprehensive molecular biology approach toward unraveling how the body’s systems go awry in complex disorders. Given the urgent need to rapidly scale interventions, these diseases also provide an ideal opportunity to make immediate progress with clinical trials for repurposed drugs.

This synergistic approach is also the most efficient and cost-effective from a financial standpoint, because it creates economies of scale and reduces redundancies that result from researching each disease piecemeal, from their respective silos. Streamlining research under one roof would also eliminate red tape and bureaucratic inefficiencies, thus ensuring the type of low barriers to entry and high return on investment (ROI) that are necessary to attract private sector participation. Moreover, a plan to fast-track FDA approval of promising drug therapies would both incentivize pharmaceutical involvement and guarantee that patients receive life-changing treatments as quickly as possible.

ME/CFS is an often lifelong condition in which about half of all patients are disabled and cannot work full-time. The level of disability for ME/CFS has been compared to that of cancer, heart disease, and last-stage AIDS. POTS is also often a lifelong condition, with a majority of patients reporting symptoms staying the same or worsening over time. Health-related quality-of-life in POTS is worse than what is seen in diabetes, neoplasms, cardiovascular disease, COPD, HIV and chronic kidney disease. Less than half of adult POTS patients are employed, and of those who are able to work, POTS symptoms prevent a majority of them from working as many hours as they would like to work. More than half of college students with POTS drop out of college due to the severity of their POTS symptoms. Given the high rate of POTS and ME/CFS with the Long Covid population, it follows that Long Covid patients can expect a similar prognosis. For all three diagnoses, there are as yet no treatments approved by the Food and Drug Administration. The landscape for drugs to treat these conditions is also undeveloped.

Given the magnitude of the challenge, a realistic budget for a Long Covid “moonshot” should be at least $1 billion per year for 10 years. Therefore, to incorporate all infection-associated chronic illnesses, the budget would need to be a great deal higher. This is an historic opportunity for the U.S. to lead with state-of-the art scientific research. A fully funded and comprehensive research program can tackle these diseases, alleviate suffering, and enable these individuals once again to pursue their dreams as productive members of society.

Several NIH offices created in recent years show us how to seize the current opportunity. In response to the most recent previous global pandemic, HIV/AIDS, the NIH created the Office of AIDS Research in 1988.

Later, the NIH established the Office of Women’s Health Research in 1990, after the Congressional Caucus for Women’s Issues asked the General Accounting Office to conduct an investigation into NIH’s implementation of guidelines for inclusion of women in medical research. The OWHR remedies longstanding inequities in which women were dramatically underrepresented in clinical research.

More recently, in 2023, the NIH launched its Office of Autoimmune Research. The office was originally proposed by then-Senator Joe Biden in 1999. In 2022, the National Academy of Sciences, Engineering, and Medicine held a research symposium, and issued a conclusive report, outlining five options for how to elevate federal research on autoimmune disease. 

One of those called for the establishment of the Office, situated within the Office of the Director. The authors noted the benefits of that high-level placement, including elevated visibility, sustained leadership, and becoming a clear focal point for intramural, extramural, training, and outreach activities. Placing it close to the NIH Director “may provide many of the benefits of a new Institute…with fewer bureaucratic costs or controversies,”they wrote.

On June 29-30, 2023, NASEM held a similar symposium to begin establishing a common research agenda for infection-associated chronic illnesses. The creation of the new Office of IACIR should organically flow out of this past summer’s NASEM meeting, just as the Office of Autoimmune Research did from the 2022 meeting.

Last year’s NASEM symposium was a watershed moment in the history of chronic illness patient advocacy movements, which for decades had effectively been voices in the wilderness. The nation’s most esteemed scientific body had consolidated the foundational literature for each condition, identified the possibilities for common pathophysiology, and illuminated a path forward. This establishes a clear generational opportunity to solve a major set of disabling conditions globally, and positions American institutions to lead in pioneering these breakthroughs.

Plan of Action

Working with champions in Congress, a select group of Administration officials – across Office of Science and Technology Policy, Domestic Policy Council, NIH, and the HHS Assistant Secretary for Health – would serve as executive sponsors and provide oversight.

Each of these primary stakeholders should take responsibility for the following steps in executing this proposal.

Clearly state the goals of the office and its NIH-wide responsibilities.

Since this research must span neurology, immunology, cardiology, pulmonology, virology, and other fields to encompass the multi-system impact of these illnesses, the Office must have a clearly-defined mission and authority to integrate work across multiple NIH institutes.

The key functions of the Office should include:

Identify leadership and staffing.

At minimum, the office would require robust staffing and could be funded through several avenues. 

To begin, the Office of IACIR’s authority could be inaugurated under the auspices of the NIH’s Common Fund. This is a highly attractive option because it wouldn’t require additional Congressional funding allocations. The fund creates a space where investigators across NIH institutes collaborate on innovative research in order to address high-priority challenges and make a broader impact on the scientific community. Among the Common Fund’s most successful initiatives is the Undiagnosed Diseases Network.

To best amplify its mission, the office should be placed within the Office of the Director. Importantly, we stipulate that the NIH Director leads this new Office in consultation with community stakeholders, who have decades of experience managing infection-associated chronic conditions.

Congress could also consider bicameral legislation to create this new NIH office. If passed, policymakers could consider taking approaches similar to those taken for AIDS and Alzheimer’s, which could mandate special oversight of this Office. AIDS legislation, for instance, requires NIH to submit a research plan directly to Congress. Alternatively, Congress should also use the authority of the Congressionally Directed Medical Research Program to support and oversee this Office.

Launch a comprehensive IACI research agenda.

The Office should create a high-level blueprint as well as a more detailed agenda with an implementation plan for carrying it out. Research projects should mirror the most recent findings and avenues for next steps discussed at the NASEM symposium.

Diagnostic research activities should include:

Clinical trial platforms should support state-of-the-art techniques including:

Not only would these approaches incorporate best practices scientifically, but by combining multiple diseases into single studies, they would create economic efficiencies that would reduce costs overall and make it easier and more cost-effective to roll out treatments.

Scale it into an Institute.

Once the new Office becomes established in the NIH and has put “points on the board” with early successes in its first five years, leaders at NIH and in the Administration should evaluate how to develop it into a Center or Institute. Alternatively, Congress could pass further legislation to elevate it to the level of an Institute.

An Institute is likely the best vehicle to fully execute a true long-term high investment capable of curing these diseases. Given the economic and social burden of these diseases – and coupled with their historic neglect – an annual research budget measured in the billions of dollars may be required.

Conclusion

Throughout its history, the NIH has continually evolved to meet new and pressing challenges as scientific understanding has progressed. Globalization, microbial resistance, and climate change continue to upset the balance of the natural world, with unpredictable effects on the human population. It’s not a question of if – but rather when – the next global pandemic will occur. Every pandemic causes long-term health consequences. The research advanced by this Office would foster pandemic resilience against the types of global infectious threats that will become increasingly common in the modern world. At the same time, it would help address the large swath of disability from the trickle-down of chronic illnesses triggered by everyday community infections as well.

Just as the NIH Office of AIDS Research has made great strides against AIDS, a new Office of Infection-Associated Chronic Illness Research will turn the tide against Long Covid and its many cousins. By diagnosing, managing, treating and ultimately curing these conditions, this program will help many millions get their lives and careers back. As they rejoin the workforce and contribute to the economy, the returns generated by this Office will exceed its costs by many orders of magnitude.

Frequently Asked Questions
How does this proposal differ from the NIH’s RECOVER initiative?
In 2021, the NIH received $1.15 billion from Congress for research to understand the long-term effects of SARS-CoV-2 over four years. It created the RECOVER Initiative, which conducts long-term observational studies of individuals experiencing post-acute sequelae of Covid-19, or PASC. RECOVER has also started to organize a few clinical trials. RECOVER’s efforts have laid a foundation. Now the NIH must go further across all fronts, including accelerated clinical trials for repurposed drugs, bolstering patient engagement, and understanding the interconnections between Long Covid and similar infection-associated chronic illnesses. This new NIH office would be a crucial hub for that ongoing research, which should become permanent.
How does this proposal complement or add to existing research at NIH?
The NIH initiated a Trans-NIH Working Group as well as an intramural research program to research ME/CFS at the National Institute of Neurological Diseases and Stroke (NINDS). In 2019, the NIH also convened a stakeholders workshop, Postural Orthostatic Tachycardia Syndrome (POTS): State of the Science, Clinical Care and Research, which led to the publication of two expert consensus papers mapping our high-priority POTS research needs.
How does the office interact with other agencies?

The Office of IACIR should dynamically collaborate with several offices at the cutting edge. First among these is the Office of Long Covid Research and Practice, established in 2023 under the Office of the Assistant Secretary for Health (OASH), includes an advisory committee composed of as many as 20 members.


Next, our future NIH Office should work in partnership with the federal government’s new health moonshot agency – the Advanced Research Projects Agency for Health (ARPA-H) – which is uniquely suited to help lead on building next-generation diagnostics for infection-associated chronic illnesses. Its model calls for rapid high-risk, high-reward science. Launched in 2022, ARPA-H is currently hiring its first slate of program managers, leading innovative projects that are disease-agnostic. Infection-associated chronic illnesses could be a target of a future ARPA-H program manager.


The Office should work closely with the Food and Drug Administration, such that safe and effective repurposed drugs can be approved for this patient population.


And throughout all of this, the Office must collaborate with the Patient Centered Outcomes Research Institute (PCORI), which has funded innovative work by the Patient Led Research Collaborative on Covid-19 to develop patient scorecards to grade the efficacy and quality of research proposals. To improve equity and stakeholder engagement, NIH should consider piggybacking off such efforts.

Which conditions should be included in this Office?
Long Covid, also called post-acute sequelae of Covid-19 (PASC); myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS); persistent Lyme disease; Gulf War illness (GWI); Ehlers Danlos syndrome (EDS); Mast cell activation syndrome (MCAS); fibromyalgia, postural orthostatic tachycardia syndrome (POTS) and other infection-triggered dysautonomias, and cranio-cervical instability (CCI).
What types of objectives might the Office tackle in its first five years?

  • Establish a consensus vocabulary; assess which chronic diseases or illnesses are “infection-associated,” and potentially expand into more areas

  • Annually develop and evaluate a strategic plan for all IACI research across NIH Institutes, Centers, and Offices

  • By the end of its first year, hold an international conference to rapidly develop a common research agenda, timeline, and milestones toward key accomplishments by 2030

  • Accelerate development of a common IACI biobank by leveraging existing disease-specific biobanking initiatives

  • Build research infrastructure to seed and sustain diverse and multidisciplinary IACI scientific workforce

  • Establish advisory council for whole-of-government approach to IACI research, care, and services

  • Involve and incentivize the private sector and fast-tracking FDA approval for promising drugs

Moving the Nation: The Role of Federal Policy in Promoting Physical Activity

Physical activity is one of the most powerful tools for promoting health and wellbeing. Movement is not only medicine—effective at treating a range of physical and mental health conditions—but it is also preventive medicine, because movement reduces the risk for many conditions ranging from cancer and heart disease to depression and Alzheimer’s disease. But rates of physical inactivity and sedentary behavior have remained high in the U.S. and worldwide for decades.

Engagement in physical activity is impacted by myriad factors that can be viewed from a social ecological perspective. This model views health and health behavior within the context of a complex interplay between different levels of influence, including individual, interpersonal, institutional, community, and policy levels. When it comes to healthy behavior such as physical activity, sustainable change is considered most likely when these levels of influence are aligned to support change. Every level of influence on physical activity within a social-ecological framework is directly or indirectly affected by federal policy, suggesting physical activity policy has the potential to bring about substantial changes in the physical activity habits of Americans. 

Every level of influence on physical activity within a social-ecological framework is directly or indirectly affected by federal policy, suggesting physical activity policy has the potential to bring about substantial changes in the physical activity habits of Americans.
FIGURE 1. Adapted from Heise, L., Elisberg, M., & Gottemoeller, M. (1999)

Why are federal physical activity policies needed?

Physical inactivity is recognized as a public health issue, having widespread impacts on health, longevity, and even the economy. Similar to other public health issues over past decades such as sanitation and tobacco use, federal policies may be the best way to coordinate large-scale changes involving cooperation between diverse sectors, including health care, transportation, environment, education, workplace, and urban planning. An active society requires the infrastructure, environment, and resources that promote physical activity. Federal policies can meet those needs by improving access, providing funding, establishing regulations, and developing programs to empower all Americans to move more. Policies also play an important role in removing barriers to physical activity, such as financial constraints and lack of safe spaces to move, that contribute to health disparities. With such a variety of factors impacting active lifestyles, physical activity policies must have inter-agency involvement to be effective.

What physical activity initiatives exist currently?

Analysis of publicly available information revealed that there are a variety of initiatives currently in place at the federal level, across several departments and agencies, aimed at increasing physical activity levels in the U.S. Information about each initiative was evaluated for their correspondence with levels of the social-ecological model, as summarized in the table. Note that it is possible the search that was conducted did not identify every relevant effort, thus there could be additional initiatives that are not included below.

Given the large number of groups with the shared goal of increasing physical activity in the nation, a memorandum of understanding (MOU) may help to promote coordination of goals and implementation strategies.

FIGURE 2. Agency roles
Department or AgencyExisting or Potential Role
Administration for Children and Families (ACF)ACF’s strategic goals include taking a “preventative and proactive approach to ensuring child, youth, family, and individual well-being.” Physical activity is a powerful preventative and proactive approach.
Administration for Community Living (ACL)ACL’s Health, Wellness, and Nutrition program addresses behavioral health, prevention of injuries and illness, and chronic disease self-management for aging and disability populations, all of which relate to physical activity, though physical activity is not directly addressed in the program’s goals.
Agency for Healthcare Research and Quality (AHRQ)AHRQ moves scientific evidence into practice to help healthcare systems and professionals deliver care that is high quality, safe, accessible, equitable, and affordable, and works to ensure that the scientific evidence is understood and used. AHRQ provides support to the U.S. Preventive Services Task Force (USPSTF), which makes recommendations about clinical preventive services including physical activity.
Centers for Disease Control and Prevention (CDC)The CDC conducts research and provides health information to tackle health problems causing death and disability for Americans, put science into action to prevent disease, and promote healthy and safe behaviors, communities and environment. The CDC has several programs focused on physical activity, partnering with other government agencies and departments as well as other organizations, including the Active People, Healthy Nation program and funding initiatives such as the State Physical Activity and Nutrition Program (SPAN 2023), which supports state-level programs to implement evidence-based strategies to address health disparities related to poor nutrition, physical inactivity, and/or obesity.
Centers for Medicare and Medicaid (CMS)CMS’ Behavioral Health Strategy is aimed at increasing access to equitable and high-quality behavioral health services and improving outcomes for people covered by Medicare, Medicaid and private health insurance. CMS could play an important role in providing access to gym memberships and exercise prescriptions for both intervention and prevention. Currently, gym memberships or fitness programs may be included in the extra coverage offered by Medicare Advantage Plans depending on the person’s location. Less commonly, coverage is provided by Medicare Supplement (Medigap) plans. For Medicaid, some states cover gym memberships as part of weight loss initiatives or partner with YMCAs or other community organizations to run health programs.
Council on Environmental Quality (CEQ) and Environmental Protection Agency (EPA)CEQ and EPA coordinate federal environmental activities and the development of environmental policy, which has a reciprocal beneficial relationship with physical activity. For example, to reduce emission and energy use, climate change policies have been introduced to encourage cycling, walking and other forms of sustainable, active transport. Parks and other green spaces that sequester carbon dioxide also provide space for people to be active. Policies that reduce air pollution help to reduce a barrier to exercising outside.
Department of Agriculture (USDA)The USDA’s strategic priorities include addressing climate change via climate smart agriculture, forestry, and clean energy. Climate, clean air, and spaces for outdoor recreation and camping such as forests are all related to physical activity. The USDA works with the Bureau of Land Management, National Park Service, and others to increase physical activity on federal land (hiking, rafting, biking, etc.), and also provides funding for urban forestry, which promotes physical activity in urban areas.
Department of Education (DE)The DE sets guidelines for physical education in schools and has provided funding for research on physical activity in schools, such as the Carol M. White Physical Education Program, which awarded grants from 2001-2015 to Local Education Agencies (LEAs) and community-based organizations (CBOs) to initiate, expand, or enhance physical education programs. The DE could also designate physical education as a core subject and ensure that physical activity is not assigned or withheld as punishment.
Department of Housing and Urban Development (HUD)HUD has an important role in community building and infrastructure. The built environment can support physical activity (e.g., by providing safe spaces for movement). For example, HUD’s Office of Community Planning and Development develops communities by promoting decent housing, suitable living environments, and expanded economic opportunities for low- and moderate-income people. Research shows that receiving HUD housing assistance is associated with higher physical activity levels in low-income Americans. HUD is also involved in the climate action plan.
Department of the Interior (DOI)The DOI manages public lands and minerals, national parks, and wildlife refuges. Within the DOI, the Bureau of Land Management and National Park Service maximize land use, including recreational activities that involve physical activity in outdoor spaces. The National Park Service promotes health and wellness through the Healthy Parks Healthy People initiative, which involves a collaboration with partners and interdisciplinary teams in the sectors of public health, medicine, conservation, and recreation to put a spotlight on the role of parks as social determinant of health.
Department of Transportation (DOT)The DOT promotes physical activity in the public sector through building and maintaining sidewalks or trails, as well as connecting them; reducing car dependency; provide increased opportunities for walking and bicycling; encouraging the creation and implementation of policies to support alternate modes of transportation; providing direct investments to supportive infrastructure such as bicycle lanes, greenways, multi use paths, sidewalks and trails; reducing distances between key destinations and providing and improving bicycle and pedestrian facilities; and installing streetlights. For example, the Safe Routes to School Programs, which promotes safe ways for youth to walk or bike to and from school through the funding of infrastructure (e.g., sidewalks) and educational programs, grew out of these federal funding programs. The DOT and its partner agencies also work to address air and noise pollution and reduce greenhouse gas emissions, to improve opportunities for safe, active, multimodal transportation and reduce dependence on vehicles, such as the Clean Air Act and the Congestion Mitigation and Air Quality Improvement (CMAQ) Program.
Department of Veterans Affairs (VA)The VA’s Veterans Health Administration is America’s largest integrated health care system. Their National Center for Health Promotion and Disease Prevention includes talking to one’s doctor about physical activity as one of their recommended preventive services. The integrated nature of medical care through the VA would promote the implementation of exercise prescriptions to a large and vulnerable population and could serve as a model for more widespread implementation.
Health Resources and Services Administration (HRSA)HRSA offers programs to improve access to health care for people who are uninsured, isolated, or medically vulnerable, and funds grants and cooperative agreements related to its mission. Funding related to physical activity is directly related to its strategic goal to “Take actionable steps to achieve health equity and improve public health.”
National Institutes of Health (NIH)As the federal government’s medical research agency, NIH supports physical activity related research in its intramural laboratories and through research funding to scientists at other organizations. Requests for applications (RFAs) and Notices of Special Interest (NOSIs) for exercise-focused research grants can promote continued research on the impacts of physical activity on health.
Office of Minority Health (OMH)The OMH promotes the health of racial and ethnic minority populations through the development of health policies and programs that will help eliminate health disparities. Prevention through physical activity and nutrition is one of OMH’s focus areas, as are clinical conditions including diabetes and hypertension that can be prevented or treated with physical activity.
Office of Personnel Management (OPM)One role of OPM, which oversees human resources for federal employees, is to help federal agencies integrate prevention strategies into their workplace through worksite health and wellness programs and organizational and employee benefits. Examples include encouraging employees to use flexible work schedules (non-duty time) to participate in health promotion activities, allowing employees to request annual leave, leave without pay, or sick leave (as appropriate) to participate in health promotion programs, and providing short periods of excused absence for health promotion programs and activities officially sponsored and administered by the agency.

The work of several agencies and departments within the federal government relates to physical activity promotion. Current initiatives are in place, but there are also opportunities for additional efforts that could further the goal of creating a more active nation.

FIGURE 3. Agency interactions
Department, Agency, or DivisionIndividualInterpersonalOrganizationalCommunityPolicy
Administration for Children and Families (ACF)XX
Administration for Community Living (ACL)XX
Agency for Healthcare Research and Quality (AHRQ)XXX
Centers for Disease Control and Prevention (CDC)XX
Centers for Medicare and Medicaid (CMS)XX
Council on Environmental Quality (CEQ)XX
Department of Agriculture (USDA)XX
Department of Education (DE)XX
Department of Housing and Urban Development (HUD)XX
Department of the Interior (DOI)XX
Department of Transportation (DOT)XX
Department of Veterans Affairs (VA)X
Environmental Protection Agency (EPA)XX
Health Resources and Services Administration (HRSA)XX
National Institutes of Health (NIH)XX
Office of Minority Health (OMH)XXX
Office of Personnel Management (OPM)XX

These and other federal departments and agencies can coordinate action with state and local partners, for example in healthcare, business and industry, education, mass media, and faith-based settings, to implement physical activity policies. 

The CDC’s Active People, Healthy Nation initiative provides an example of this approach. This campaign, launched in 2020, has the goal of helping 27 million Americans become more physically active by 2027. By taking action steps focused on program delivery, partnership engagement, communication, training, and continuous monitoring and evaluation, the campaign seeks to help communities implement evidence-based strategies across sectors and settings to provide equitable and inclusive access to safe spaces for physical activity. According to our analysis, the strategies of the Active People, Healthy Nation initiative are aligned with the social-ecological model. The Physical Activity Policy Research and Evaluation Network, a research partner of the Active People, Healthy Nation initiative, provides an example of coordinating with partners in other sectors to promote physical activity. Through collaboration across sectors, the network brings together diverse partners to put into practice research on environments that maximize physical activity. The network includes work groups focused on equity and inclusion, parks and green space, rural active living, school wellness, transportation policy and planning, and business/industry.

The Biden-Harris Administration National Strategy on Hunger, Nutrition, and Health, announced in September 2022, also includes strategies that are consistent with a social-ecological model. The strategy outlines steps toward the goal of ending hunger and increasing healthy eating and physical activity by 2030 so that fewer Americans will experience diet-related diseases. Pillar 4 of the strategy is to “make it easier for people to be more physically active—in part by ensuring that everyone has access to safe places to be active—increase awareness of the benefits of physical activity, and conduct research on and measure physical activity.” The strategy specifies goals such as building environments that promote physical activity (e.g., connecting people to parks; promoting active transportation and land use policies to support physical activity) and includes a call to action for a whole-of-society response involving the private sector, state, local, and territory governments, schools, and workplaces.

The Congressional Physical Activity Caucus has been active in introducing legislation that can help realize the goals of the current physical activity initiatives. For example, in February 2023, Sen. Sherrod Brown (D-OH), co-chair of the Caucus, introduced the Promoting Physical Activity for Americans Act, a bill that would require the Department of Health and Human Services to continue issuing evidence-based physical-activity guidelines and detailed reports at least every 10 years, including recommendations for population subgroups (e.g., children or individuals with disabilities). In addition, members of the Caucus, along with other members of congress, reintroduced the bipartisan, bicameral Personal Health Investment Today (PHIT) Act in March 2023. This legislation seeks to encourage physical activity by allowing Americans to use a portion of the money saved in their pre-tax health savings account (HSA) and flexible spending account (FSA) toward qualified sports and fitness purchases, such as gym memberships, fitness equipment, physical exercise or activity programs and youth sports league fees. The bill would also allow a medical care tax deduction for up to $1,000 ($2,000 for a joint return or a head of household) of qualified sports and fitness expenses per year.

What progress has been made?

There are signs that some of the national campaigns are leading to changes at other levels of society. For example, 46 cities, towns, and states have passed an Active People, Healthy Nation Proclamation as of September 2023. According to the State Routes Partnership, which develops “report cards” for states based on their policies supporting walking, bicycling, and active kids and communities, many states have shown movement in their policies between 2020 and 2022, such as implementing new policies to support walking and biking and increasing state funding for active transportation. However, more time is needed to determine the extent to which recent initiatives are helping to create a more active country, since most were initiated in the past two or three years. Predating the current initiatives, the overall physical activity level of Americans increased from 2008 to 2018, but there has been little change since that time, and only about one-quarter of adults meet the physical activity guidelines established by the CDC.

Clearly, there is a critical need for concerted effort to implement the strategies outlined in current physical activity initiatives so that national policies have the intended impacts on communities and on individuals. Leveraging provisions in existing legislation related to the social-ecological model of physical activity promotion will also help with implementation. For example, title III-D of the Older Americans Act supports healthy lifestyles and promotes healthy behaviors amongst older adults (age 60 and older), providing funding for evidence-based programs that have been proven to improve health and well-being and reduce disease and injury. Physical activity programs are prime candidates for such funding. In addition, programs under the 2021 Bipartisan Infrastructure Law and the 2022 Inflation Reduction Act are helping to change the current car-dependent transportation network, providing healthier and more sustainable transportation options, including walking, biking, and using public transportation, and are providing investments in environmental programs to improve public health and reduce pollution. For example, states can use funds from the Highway Safety Improvement Program for bicycle and pedestrian highway safety improvement projects, and funding is available through the Carbon Reduction Program for programs that help reduce dependence on single-occupancy vehicles, such as public transportation projects and the construction, planning, and design of facilities for pedestrians, bicyclists, and other non-motorized forms of transportation.

Partnering with non-governmental groups working towards common goals, such as the Physical Activity Alliance, can also help with implementation. The Alliance’s National Physical Activity Plan is based on the socio-ecological model and includes recommendations for evidence-based actions for 10 societal sectors at the national, state, local and institutional levels, with a focus on making change at the community level. The plan shares many priorities with those of the Active People, Healthy Nation initiative, while also introducing new goals, such as establishing a CDC Office of Physical Activity and Health. 

With coordinated action based on established public health models, such as the social-ecological framework, federal policies can be successfully implemented to make the systemic changes that are needed to create a more active nation.


The work for this blog was undertaken before Dr. Dotson joined the Agency for Healthcare Research and Quality (AHRQ). Dr. Dotson is solely responsible for this blog post’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement as an official position of AHRQ or of the U.S. Department of Health and Human Services.

Towards a Well-Being Economy: Establishing an American Mental Wealth Observatory

Summary

Countries are facing dynamic, multidimensional, and interconnected crises. The pandemic, climate change, rising economic inequalities, food and energy insecurity, political polarization, increasing prevalence of youth mental and substance use disorders, and misinformation are converging, with enormous sociopolitical and economic consequences that are weakening democracies, corroding the social fabric of communities, and threatening social stability and national security. Globalization and digitalization are synchronizing, amplifying, and accelerating these crises globally by facilitating the rapid spread of disinformation through social media platforms, enabling the swift transmission of infectious diseases across borders, exacerbating environmental degradation through increased consumption and production, and intensifying economic inequalities as digital advancements reshape job markets and access to opportunities.

Systemic action is needed to address these interconnected threats to American well-being.

A pathway to addressing these issues lies in transitioning to a Well-Being Economy, one that better aligns and balances the interests of collective well-being and social prosperity with traditional economic and commercial interests. This paradigm shift encompasses a ‘Mental Wealth’ approach to national progress, recognizing that sustainable national prosperity encompasses more than just economic growth and instead elevates and integrates social prosperity and inclusivity with economic prosperity. To embark on this transformative journey, we propose establishing an American Mental Wealth Observatory, a translational research entity that will provide the capacity to quantify and track the nation’s Mental Wealth, generate the transdisciplinary science needed to empower decision makers to achieve multisystem resilience, social and economic stability, and sustainable, inclusive national prosperity.

Challenge and Opportunity

America is facing challenges that pose significant threats to economic security and social stability. Income and wealth inequalities have risen significantly over the last 40 years, with the top 10% of the population capturing 45.5% of the total income and 70.7% of the total wealth of the nation in 2020. Loneliness, isolation, and lack of connection are a public health crisis affecting nearly half of adults in the U.S. In addition to increasing the risk of premature mortality, loneliness is associated with a three-fold greater risk of dementia

Gun-related suicides and homicides have risen sharply over the last decade. Mental disorders are highly prevalent. Currently, more than 32% of adults and 47% of young people (18–29 years) report experiencing symptoms of anxiety and depression. The COVID-19 pandemic compounded the burden, with a 25–30% upsurge in the prevalence of depressive and anxiety disorders. America is experiencing a social deterioration that threatens its continued prosperity, as evidenced by escalating hate crimes, racial tensions, conflicts, and deepening political polarization. 

To reverse these alarming trends in America and globally, policymakers must first acknowledge that these problems are interconnected and cannot effectively be tackled in isolation. For example, despite the tireless efforts of prominent stakeholder groups and policymakers, the burden of mental disorders persists, with no substantial reduction in global burden since the 1990s. This lack of progress is evident even in high-income countries where investments in and access to mental health care have increased. 

Strengthening or reforming mental health systems, developing more effective models of care, addressing workforce capacity challenges, leveraging technology for scalability, and advancing pharmaceuticals are all vital for enhancing recovery rates among individuals grappling with mental health and substance use issues. However, policymakers must also better understand the root causes of these challenges so we can reshape the economic and social environments that give rise to common mental disorders.

Understanding and Addressing the Root Causes 

Prevention research and action often focus on understanding and addressing the social determinants of health and well-being. However, this approach lacks focus. For example, traditional analytic approaches have delivered an extensive array of social determinants of mental health and well-being, which are presented to policymakers as imperatives for investment. These include (but are not limited to):

This practice is replicated across other public health and social challenges, such as obesity, child health and development, and specific infectious and chronic diseases. Long lists of social determinants lobbied for investment lead policymakers to conclude that nations simply can’t afford to invest sufficiently to solve these health and social challenges. 

However, it Is likely that many of these determinants and challenges are merely symptoms of a more systemic problem. Therefore, treating the ongoing symptoms only perpetuates a cycle of temporary relief, diverts resources away from nurturing innovation, and impedes genuine progress.

To create environments that foster mental health and well-being, where children can thrive and fulfill their potential, where people can pursue meaningful vocation and feel connected and supported to give back to communities, and where Americans can live a healthy, active, and purposeful life, policymakers must recognize human flourishing and prosperity of nations depends on a delicate balance of interconnected systems.

The Rise of Gross Domestic Product: An Imperfect Measure for Assessing the Success and Wealth of Nations

To understand the roots of our current challenges, we need to look at the history of the foundational economic metric, gross domestic product (GDP). While the concept of GDP had been established decades earlier, it was during a 1960 meeting of the Organization for Economic Co-operation and Development that economic growth became a primary ambition of nations. In the shadow of two world wars and the Great Depression, member countries pledged to achieve the highest sustainable economic growth, employment, efficiency, and development of the world economy as their top priority (Articles 1 & 2). 

GDP growth became the definitive measure of a government’s economic management and its people’s welfare. Over subsequent decades, economists and governments worldwide designed policies and implemented reforms aimed at maximizing economic efficiency and optimizing macroeconomic structures to ensure consistent GDP growth. The belief was that by optimizing the economic system, prosperity could be achieved for all, allowing governments to afford investments in other crucial areas. However, prioritizing the optimization of one system above all others can have unintended consequences, destabilizing interconnected systems and leading to a host of symptoms we currently recognize as the social determinants of health. 

As a result of the relentless focus on optimizing processes, streamlining resources, and maximizing worker productivity and output, our health, social, political, and environmental systems are fragile and deteriorating. By neglecting the necessary buffers, redundancies, and adaptive capacities that foster resilience, organizations and nations have unwittingly left themselves exposed to shocks and disruptions. Americans face a multitude of interconnected crises, which will profoundly impact life expectancy, healthy development and aging, social stability, individual and collective well-being, and our very ability to respond resiliently to global threats. Prioritizing economic growth has led to neglect and destabilization of other vital systems critical to human flourishing.

Shifting Paradigms: Building the Nation’s Mental Wealth 

The system of national accounts that underpins the calculation of GDP is a significant human achievement, providing a global standard for measuring economic activity. It has evolved over time to encompass a wider range of activities based on what is considered productive to an economy. As recently as 1993, finance was deemed “explicitly productive” and included in GDP. More recently, Biden-Harris Administration leaders have advanced guidance for accounting for ecosystem services in benefit-cost analyses for regulatory decision-making and a roadmap for natural capital inclusion in the nation’s economic accounting services. This shows the potential to expand what counts as beneficial to the American economy—and what should be measured as a part of economic growth.

While many alternative indices and indicators of well-being and national prosperity have been proposed, such as the genuine progress indicator, the vast majority of policy decisions and priorities remain focused on growing GDP. Further, these metrics often fail to recognize the inherent value of the system of national accounts that GDP is based on. To account for this, Mental Wealth is a measure that expands the inputs of GDP to include well-being indicators. In addition to economic production metrics, Mental Wealth includes both unpaid activities that contribute to the social fabric of nations and social investments that build community resilience. These unpaid activities (Figure 1, social contributions, Cs) include volunteering, caregiving, civic participation, environmental restoration, and stewardship, and are collectively called social production. Mental Wealth also includes the sum of investment in community infrastructure that enables engagement in socially productive activities (Figure 1, social investment, Is). This more holistic indicator of national prosperity provides an opportunity to shift policy priorities towards greater balance between the economy and broader societal goals and is a measure of the strength of a Well-Being Economy. 

Figure 1.

Mental wealth is a more comprehensive measure of national prosperity that monetizes the value generated by a nation’s economic and social productivity.

Valuing social production also promotes a more inclusive narrative of a contributing life, and it helps to rebalance societal focus from individual self-interest to collective responsibilities. A recent report suggests that, in 2021, Americans contributed more than $2.293 trillion in social production, equating to 9.8% of GDP that year. Yet social production is significantly underestimated due to data gaps. More data collection is needed to analyze the extent and trends of social production, estimate the nation’s Mental Wealth, and assess the impact of policies on the balance between social and economic production.

Unlocking Policy Insights through Systems Modeling and Simulation

Systems modeling plays a vital role in the transition to a Well-Being Economy by providing an understanding of the complex interdependencies between economic, social, environmental, and health systems, and guiding policy actions. Systems modeling brings together expertise in mathematics, biostatistics, social science, psychology, economics, and more, with disparate datasets and best available evidence across multiple disciplines, to better understand which policies across which sectors will deliver the greatest benefits to the economy and society in balance. Simulation allows policymakers to anticipate the impacts of different policies, identify strategic leverage points, assess trade-offs and synergies, and make more informed decisions in pursuit of a Well-Being Economy. Forecasting and future projections are a long-standing staple activity of infectious disease epidemiologists, business and economic strategists, and government agencies such as the National Oceanic and Atmospheric Administration, geared towards preparing the nation for the economic realities of climate change.

Plan of Action 

An American Mental Wealth Observatory to Support Transition to a Well-Being Economy

Given the social deterioration that is threatening America’s resilience, stability, and sustainable economic prosperity, the federal government must systemically redress the imbalance by establishing a framework that privileges an inclusive, holistic, and balanced approach to development. The government should invest in an American Mental Wealth Observatory (Table 1) as critical infrastructure to guide this transition. The Observatory will report regularly on the strength of the Well-Being Economy as a part of economic reporting (see Table 1, Stream 1); generate the transdisciplinary science needed to inform systemic reforms and coordinated policies that optimize economic, environmental, health and social sectors in balance such as adding Mental Wealth to the system of national accounts (Streams 2–4); and engage in the communication and diplomacy needed to achieve national and international cooperation in transitioning to a Well-Being Economy (Streams 5–6).

This transformative endeavor demands the combined instruments of science, policy, politics, public resolve, social legislation, and international cooperation. It recognizes the interconnectedness of systems and the importance of a systemic and balanced approach to social and economic development in order to build equitable long-term resilience, a current federal interagency priority. The Observatory will make better use of available data from across multiple sectors to provide evidence-based analysis, guidance, and advice. The Observatory will bring together leading scientists (across disciplines of economics, social science, implementation science, psychology, mathematics, biostatistics, business, and complex systems science), policy experts, and industry partners through public-private partnerships to rapidly develop tools, technologies, and insights to inform policy and planning at national, state, and local levels. Importantly, the Observatory will also build coalitions between key cross-sectoral stakeholders and seek mandates for change at national and international levels. 

The American Mental Wealth Observatory should be chartered by the National Science and Technology Council, building off the work of the White House Report on Mental Health Research Priorities. Federal partners should include, at a minimum, the Department of Health and Human Services (HHS) Office of the Assistant Secretary for Health (OASH), specifically the Office of the Surgeon General (OSG) and Office of Disease Prevention and Health Promotion (ODPHP); the Substance Abuse and Mental Health Services Administration (SAMHSA); the Office of Management and Budget; the Council of Economic Advisors (CEA); and the Department of Commerce (DOC), alongside strong research capacity provided by the National Science Foundation (NSF) and the National Institutes of Health (NIH).

Table 1. Blueprint for an American Mental Wealth Observatory
The aim of the American Mental Wealth Observatory is to provide the data and science needed to act systemically to transition to a Well-Being Economy, build multi-system resilience, human flourishing, and national prosperity. The Observatory will have 6 overlapping streams of activity.
Stream 1: Measuring and monitoring the nation’s mental wealth (CEA, OSTP, OMB, DOC)While a number of communities and nations are embracing Well-Being Economy frameworks and tracking progress against a broad range of indicators of individual and societal well-being, an overarching measure of progress is needed. Without it, GDP will remain a privileged indicator that policy levers are trained on. This stream is focused on the further evolution of GDP to be a more holistic topline indicator of the strength of a Well-Being Economy: Mental Wealth. National Mental Wealth will be estimated and reported annually in the establishment phase, followed by quarterly intervals to mirror reporting of GDP. This effort can build on existing frameworks developed by DOC to include natural capital accounting within the system of national accounts, including linking Mental Wealth accounts with national economic accounts, interagency coordination and data standardization and interoperability policy, and organizing the development of a U.S. system of statistics for Mental Wealth decision-making.
Stream 2: Complex systems modeling and simulation (NSF, NIH, OASH, SAMHSA, OSTP, DOC)Advancing from rudimentary analytic and decision support tools to harnessing complex systems modeling and simulation will inform greater alignment of policies across economic, social, and health systems to enhance Mental Wealth (economic and social prosperity). Systems models are platforms for Living Evidence. Developing systems models requires the integration of scientific theory with best available research evidence and diverse data sources in a way that allows decision makers to test alternative policies and initiatives or ask resource allocation questions in a safe virtual environment before implementing them in the real world. As new evidence and data become available, models are updated/refined, becoming more robust over time, and offering significant value as long-term decision support assets.
Stream 3: Strengthening transdisciplinary data ecosystems (SAMHSA, OASH, DOC, OMB, OSTP, CEA, NIH, NSF)Strengthening transdisciplinary data ecosystems by harnessing advances in technology and passive and/or sentinel surveillance is essential, and will provide intelligence to inform coordinated cross-sectoral policy and planning.
This stream will also support early detection and rapid response to system stress and inform both Stream 2 modeling and Stream 4 Brain Capital research program. This program will include the establishment of a U.S. Brain Capital Dashboard and ongoing monitoring of brain capital indicators across three pillars: brain capital drivers (social, digital, economic), brain health (including mental health, well-being, and neurological disorders), and brain skills (cognitive and emotional skills and education metrics.
In addition, innovative protocols are being developed. For example, a protocol for scalable wastewater monitoring of stress hormones like cortisol and cortisone is under development in order to gain near-real-time insights into community stress and inform rapid deployment of resources/infrastructure to support communities through difficult times and prevent social decline before it becomes entrenched.
Stream 4: Brain Capital research program (NSF, NIH, OSTP)Investing in research that prioritizes brain capital enhancement opens doors to understanding and harnessing the economic value of human cognitive abilities (coupled with augmented intelligence offered by generative AI), mental health, and overall brain functioning. Recognizing and nurturing the economic value of brain capital can pave the way for a more prosperous and sustainable future, where individuals and societies thrive both intellectually and economically.
This research program will harness advanced research technologies to answer priority questions such as:


  • What are the likely impacts of AI on the diffusion of productivity gains, wealth, and well-being?

  • What are the projected impacts of early childhood education and care (ECEC) on school readiness, workforce participation, and family income?

  • What is the relationship between social capital infrastructure investment, social connectedness, and mental health in young people?

  • How is AI changing the nature of work, well-being, and productivity?

  • What is the optimal balance of digital technologies and human workforces needed to scale mental health and social care to meet demand?

  • How can employers and educators work together to create workforces and workplaces that are adaptable to changing circumstances by mastering quality, transferable vocational skills?
Stream 5: Knowledge translation / Policy Lab (CEA, OMB, OSTP, external nonprofits and academic research institutions)Shifting entrenched economic narratives and frameworks requires transdisciplinary policy advocacy, knowledge translation, and public communications alongside private stakeholders because stable transition to a Well-Being Economy will require broad scientific, policy, and public support as well as better cooperation between public and private sectors.
Stream 6: Brain Health / Science diplomacy (OSTP, State Department)Nothing less than an ambitious, innovative, transdisciplinary, and coordinated transnational research agenda is needed to enable the transition to a Well-Being Economy. The open sharing of insights, tools, and metrics across global agencies is needed to elevate mental health’s importance as a policy focus and inform policy and advocacy efforts and momentum for change. Therefore, this stream will focus on building bridges between countries through a universal appreciation of the importance of the integrity of the social fabric of nations for a nation’s very stability and resilience. Science diplomacy will also be important in facilitating the sharing of knowledge and innovations across borders, as well as for fostering international cooperation.

Operationalizing the American Mental Wealth Observatory will require an annual investment of $12 million from diverse sources, including government appropriations, private foundations, and philanthropy. This funding would be used to implement a comprehensive range of priority initiatives spanning the six streams of activity (Table 2) coordinated by the American Mental Wealth Observatory leadership. Acknowledging the critical role of brain capital in upholding America’s prosperity and security, this investment offers considerable returns for the American people.

Table 2. Investment needed to actualize an American Mental Wealth Observatory
Budget (US$M)
Stream20242025202620272028
Stream 1: Measuring and monitoring the Mental Wealth of the nation1.51.71.71.71.7
Stream 2: Complex systems modeling and simulation2.32.82.82.82.8
Stream 3: Strengthening transdisciplinary data ecosystems2.83.03.73.13.1
Stream 4: Brain Capital research program2.53.03.03.02.5
Stream 5: Knowledge translation/Policy Lab1.51.51.51.51.5
Stream 6: Brain Health/Science Diplomacy0.70.70.70.70.7
Total11.312.713.412.812.3

Conclusion

America stands at a pivotal moment, facing the aftermath of a pandemic, a pressing crisis in youth mental and substance use disorders, and a growing sense of disconnection and loneliness. The fragility of our health, social, environmental, and political systems has come into sharp focus, and global threats of climate change and generative AI loom large. There is a growing sense that the current path is unsustainable. 

After six decades of optimizing the economic system for growth in GDP, Americans are reaching a tipping point where losses due to systemic fragility, disruption, instability, and civil unrest will outweigh the benefits. The United States government and private sector leaders must forge a new path. The models and approaches that guided us through the 20th century are ill-equipped to guide us through the challenges and threats of the 21st century.

This realization presents an extraordinary opportunity to transition to a Well-Being Economy and rebuild the Mental Wealth of the nations. An American Mental Wealth Observatory will provide the data and science capacity to help shape a new generation grounded in enlightened global citizenship, civic-mindedness, and human understanding and equipped with the cognitive, emotional, and social resources to address global challenges with unity, creativity, and resilience.

The University of Sydney’s Mental Wealth Initiative thanks the following organizations for their support in drafting this memo: FAS, OECDRice University’s Baker Institute for Public PolicyBoston University School of Public Health, the Brain Capital Alliance, and CSART.

Frequently Asked Questions
What is brain capital?

Brain capital is a collective term for brain skills and brain health, which are fundamental drivers of economic and social prosperity. Brain capital comprises (1) brain skills, which includes the ability to think, feel, work together, be creative, and solve complex problems, and (2) brain health, which includes mental health, well-being, and neurological disorders that critically impact the ability to use brain skills effectively, for building and maintaining positive relationships with others, and for resilience against challenges and uncertainties.

What is the social benefit of valuing unpaid forms of labor (social production)?

Social production is the glue that holds society together. These unpaid social contributions foster community well-being, support our economic productivity, improve environmental wellbeing, and help make us more prosperous and resilient as a nation.


Social production includes volunteering and charity work, educating and caring for children, participating in community groups, and environmental restoration—basically any activity that contributes to the social fabric and community well-being.


Making the value of social production visible helps us track how economic policies are affecting social prosperity and allows governments to act to prevent an erosion of our social fabric. So instead of just measuring our economic well-being through GDP, measuring and reporting social production as well gives us a more holistic picture of our national welfare. The two combined (GDP plus social production) is what we call the overall Mental Wealth of the nation, which is a measure of the strength of a Well-Being Economy.

As a society, what do we stand to lose by not measuring the Mental Wealth of the nation?

The Mental Wealth metric extends GDP to include not only the value generated by our economic productivity but also the value of this social productivity. In essence, it is a single measure of the strength of a Well-Being Economy. Without a Mental Wealth assessment, we won’t know how we are tracking overall in transitioning to such an economy.


Furthermore, GDP only includes the value created by those in the labor market. The exclusion of socially productive activities sends a signal that society does not value the contributions made by those not in the formal labor market. Privileging employment as a legitimate social role and indicator of societal integration leads to the structural and social marginalization of the unemployed, older adults, and the disabled, which in turn leads to lower social participation, intergenerational dependence, and the erosion of mental health and well-being.

How do well-being frameworks compare to Mental Wealth, and why are you proposing something different?

Well-being frameworks are an important evolution in our journey to understand national prosperity and progress in more holistic terms. Dashboards of 50-80 indicators like those proposed in Australia, Scotland, New Zealand, Iceland, Wales, and Finland include things like health, education, housing, income and wealth distribution, life satisfaction, and more, which help track some important contributors to social well-being.


However, these sorts of dashboards are unlikely to compete with topline economic measures like GDP as a policy focus. Some indicators will go up, some will go down, some will remain steady, so dashboards lack the ability to provide a clear statement of overall progress to drive policy change.


We need an overarching measure. Measurement of the value of social production can be integrated into the system of national accounts so that we can regularly report on the nation’s overall economic and social well-being (or Mental Wealth). Mental Wealth provides a dynamic measure of the strength (and good management) of a Well-Being Economy. By adopting Mental Wealth as an overarching indicator, we also gain an improved understanding of the interdependence of a healthy economy and a healthy society.

Expanding the Health Policy Mission of the Veterans Health Administration

Summary

With 1,255 VA medical facilities serving over 9 million veterans each year, the VA — through its Veterans Health Administration — maintains the largest integrated healthcare system in the United States. The VA is a national leader in delivering quality health services and driving innovation in high-priority healthcare issues such as telehealth, precision medicine, suicide prevention, and opioid safety. Yet the VA remains an under-appreciated and underutilized health policy stakeholder, involved in minimal interactions with other federal health agencies and exerting limited influence on the private healthcare system. This is a mistake. The VA is a robust healthcare provider with innovative clinical and operational practices that should be firmly entrenched in the national health policy conversation.

As a remedy, we propose strategically coordinating and consolidating the healthcare innovation, demonstration, and implementation capacities of the VA and HHS in order to ensure care of the highest possible quality across urgent issues. Elevating the VA as a major healthcare policy stakeholder will demonstrate the value of government-run healthcare, promote best practices for building an effective and forward-thinking healthcare system, and advance the VA’s “fourth mission” of supporting national preparedness.