The third session of the June 2021 workshop featured two presentations on innovative policy solutions and policy opportunities and challenges, which were followed by a panel discussion and question-and-answer period with workshop participants. Stephanie Navarro Silvera, professor of public health at Montclair State University, moderated the session and provided opening remarks.
Silvera reiterated comments she had made during the first workshop to distinguish between large “P” and small “p” policies. Large “P” policies include broad federal, state, and local laws that may be specific to health (e.g., access to universal health care) or not specific to health yet potentially can influence health outcomes (e.g., policies related to voting rights, housing, and education). These policies often influence small “p” policies, she explained, which include organizational practices and policies such as those that govern workplaces or school food systems. Small “p” policies can also influence large “P” policies, she added, through funding availability, enforcement, attention, and equitability of policy application.
Silvera elaborated on the equity aspect of policy development, urging consideration of who (i.e., which individuals and populations) is and is not involved in decisions related to defining a problem and determining potential solutions to address it. When some populations are outside of that “circle of power,” she suggested, their absence influences the language used, the data that are collected and prioritized, the interpretation of those data, and ultimately the details of the policy developed. She added that excluded populations may be historically disenfranchised, and that exclusion from the policy cycle omits their voices from both policy development and assessment; therefore, their perspectives on a policy’s impact (whether positive or negative) are also absent. Silvera closed her remarks with a quote from Mikki Kendall: “We have to be willing to embrace the full autonomy of people who are less privileged and understand that equity means making access to opportunity easier, not deciding which opportunities those individuals deserve.”
A PERSPECTIVE FROM THE INTERTRIBAL AGRICULTURE COUNCIL
Colby D. Duren, director of policy and government relations at the Intertribal Agriculture Council (IAC), discussed the council’s work and approach to policy innovation. He explained that the IAC was established in 1987 in the wake of the farm financial crisis, which disproportionately affected tribal producers. In recognition of the inequities these producers experienced, the IAC was directed to provide them with direct assistance and support, as well as to support relevant policy developments.
Tribal producers were not envisioned as original stakeholders in the U.S. Department of Agriculture’s (USDA’s) foundational policies,
Duren maintained, and the IAC continues to advocate for tribal producers’ access to the funding and support available through USDA programs. One approach to this end involves technical assistance agents who work directly with tribal producers to illuminate producer’s concerns and their challenges in accessing programs, funding, or other opportunities. The IAC reviews this feedback, Duren added, and determines whether the issues can be addressed through USDA or need to be elevated to Congress.
Duren referenced recent progress toward including tribes in federal farm policies, noting that tribes were mentioned in the Farm Bill for the first time in 1990. He pointed out that because USDA is not structured around the realities of tribal agriculture, the IAC works to have a voice in the process of agricultural policy making as early on as possible. He reminded participants that as sovereign governments, tribes have a unique and direct nation-to-nation relationship with the federal government and are continuous stakeholders in its programs, a status that warrants consulting tribes prior to and during the creation of federal policies.
Duren described the formation of the Native Farm Bill Coalition, which started as a research and data-gathering effort leading up to the 2018 Farm Bill. That effort engaged the Indigenous Food and Agriculture Initiative at the University of Arkansas, he recounted, to produce an extensive report titled Regaining Our Future (Hipp and Duren, 2017). The report reviewed the history of tribal agriculture and suggested opportunities for the Farm Bill’s policies to serve tribal producers. The IAC used the report to engage tribal organizations across the country, Duren continued, which worked together to develop and distribute dissemination materials aimed at spurring conversation about the report and advocating for its suggested policy changes. Duren added that the Native Farm Bill Coalition now includes 17 national tribal organizations and 3 allied organizations and represents more than 170 tribes.
Duren next described challenges faced by the coalition in effectively translating the report to help policy makers understand how the proposed policy changes would benefit tribal producers. He observed that stakeholders in federal government programs often use shorthand phrases and acronyms to communicate program data, which he said had to be translated and supported with additional context to help convey the data’s meaning. In many cases, he noted, few data were available to describe the impact of federal programs on tribal producers and communities, which he identified as an impediment to building a compelling case for change. Duren highlighted the importance of using stories to help fill data gaps and to provide decision makers with tangible examples of how proposed policies would benefit people on the ground. He maintained that, even in the presence of abundant data and sound analyses indicating a proposed policy’s effectiveness, clear examples of a policy’s practical benefits for constituents can have a unique impact.
Returning to 2018, Duren relayed that the coalition was able to help secure 63 tribal-specific provisions in that year’s Farm Bill. One of the most important wins was the extension of tribal self-governance, which he described as the ability for tribal governments to contract with the federal government to administer and manage a program designed to serve its citizens. According to Duren, one way that authority manifests is the Food Distribution Program on Indian Reservations (FDPIR), a commodity food purchasing program that allows distribution sites to contract with and purchase food from local producers. This has a double benefit, Duren explained, as it gives program recipients the opportunity to access foods that are traditional to their region while also helping local producers build their capacity by connecting them with a federal government program. Duren reported that the IAC has been working on implementation of the Farm Bill’s provisions, which he said is at least half the battle (the other half being enactment/passage) in achieving a policy’s intent.
Duren ended his remarks by underscoring the importance of ensuring tribal representation from the initiation of policy through its development, implementation, and assessment. He reiterated that tribal producers have historically been in a reactive position because they have been excluded from this process, which he said left them “trying to fit the square peg of tribal agriculture into a round policy hole.” Even if tribal stakeholders are able to advocate successfully for adjustments to proposed or enacted policies, Duren observed they are still subject to a program that may not be as helpful as it could be for the people it is intended to serve. In closing, he stated that the IAC will continue to build relationships that help tribal stakeholders achieve equitable opportunities through early and deep engagement in policy initiation, development, implementation, and evaluation.
A PERSPECTIVE ON INNOVATIVE LOCAL GOVERNMENT APPROACHES
Mary T. Bassett, director of the François-Xavier Bagnoud (FXB) Center for Health and Human Rights at Harvard University and FXB professor of the practice of health and human rights at the Harvard T.H. Chan School of Public Health, reflected on her tenure as deputy health commissioner (2002–2009) and health commissioner (2014–2018) in New York City (NYC). According to Basset, the position of the NYC Department of Health on equity during those years was that “a rising tide would raise all boats.” In other words, she clarified, a specific equity lens did not exist because a policy initiative that would advance the availability of and ability to make healthy food choices was expected to be good for everyone.
Bassett explained that the NYC Department of Health’s various policy approaches were aimed at countering the rising prevalence of overweight,
obesity, and diabetes among the city’s residents. She acknowledged that these approaches were innovative, but said they seemed like common sense in light of available data on the city population’s rates of overweight, obesity, and diabetes, as well as the structural context that had affected the way people obtained food and were prompted to consume calories from purchased and prepared foods. Bassett highlighted wide variation at the neighborhood level—mainly by race, ethnicity, and income—in the prevalence of these conditions and of self-reported consumption of calorie-dense foods and sugar-sweetened beverages. To her, it seemed clear that the rising prevalence of adverse health indicators could not be attributed to individual choices alone, which she said led to the Department of Health’s realization that improving the availability and accessibility of healthy food choices is at least as important as educating people about making healthy choices—if not more so.
Bassett went on to describe several policy approaches pioneered by the NYC Department of Health, beginning with its 2006 requirements for chain restaurants to post calorie information on their menus and for all restaurants to remove trans fats from most of their menu offerings. In 2008, she continued, the city used executive authority to establish nutrition standards for snacks and beverages purchased by the city and brokered an agreement to remove sugary beverages from public school vending machines. Arguably the most well-known action taken by the Department of Health was its 2012 attempt to limit the serving size of sugar-sweetened beverages in food service establishments, Bassett recalled, a measure that was highly contested and ultimately overturned in the courts. She noted that prior policies had also faced legal challenges, usually on the basis of federal preemption or corporate free speech, but had nonetheless prevailed. In 2015, the Department of Health instituted warning labels on chain restaurant menu items containing more than the daily recommended intake of sodium. Local jurisdictions followed NYC’s lead in adopting some of these policies, Bassett said, which subsequently garnered national attention. She cited two examples: calorie posting in chain restaurants as part of the Patient Protection and Affordable Care Act of 2010, and Food and Drug Administration actions to lower trans fat and sodium content across the food supply.
More action at the national level is critical, Bassett asserted, given limits to the power of local authorities to make healthy choices available to their residents. She expressed the hope that future actions would target ultraprocessed foods, which she said are low cost and readily available and furnish a majority of the calories in U.S. diets. In her view, more than information, education, and individual willpower will be required to confront the rising tide of inexpensive, calorie-dense options in the current food and beverage environment.
PANEL AND AUDIENCE DISCUSSION
Following their presentations, Duren and Bassett responded to questions from workshop participants about the development of inclusive food policies, approaches for building support for public health policy approaches, taxation as a potential obesity solution, distribution of benefits from USDA funding and programs, and issues of preemption.
The Development of Inclusive Food Policies
Duren urged those advocating for food policies that would benefit Indigenous populations and other communities of color to include researchers and data representative of those populations in those efforts. He also believes it would be valuable for federal dietary guidance to include examples of healthy foods representing the diverse cultures of people who live in the United States. To illustrate these points, he recounted that when tribal stakeholders participated in policy development and advocacy efforts related to the FDPIR, the result was an increase in program recipients’ access to more healthy and traditional food options.
Approaches for Building Support for Public Health Policy Approaches
According to Bassett, an increasingly common yet misguided approach for addressing obesity is to modify the individual instead of the environment. Treating people with obesity is important, she clarified, but she argued that the condition’s high prevalence warrants population-level approaches as well. The trajectory of the prevalence of overweight, obesity, and type 2 diabetes in the United States is associated with changes in the country’s food environment, she observed, and she called for more robust federal action to shift the composition of the nation’s food supply. She pointed out that social movements have driven community-grown strategies, such as those focused on increasing neighborhood availability of healthy food and promoting urban agriculture. She contrasted such efforts with “top down” approaches—i.e., larger-scale policy changes—that the NYC Department of Health pursued.
In response to a question about guidance for the upcoming generation of change makers, Bassett urged advocating for regulation of the large industrial complexes that she said control the food system, and for providing data that can build the case for restructuring the food production landscape to support a healthier food supply. According to Duren, the current environment is fertile for making changes on a large scale in light of technologies for rapidly disseminating messages with the potential for broad reach. On that note, he emphasized the importance of a consistent,
accurate stream of data and information for inclusion in daily news cycles about a proposed policy and its potential benefits for the intended recipients. He urged youth to be bold in making their voices and stories heard, which he claimed is particularly impactful when they speak about how a proposed policy would affect them.
Taxation as a Potential Obesity Solution
Bassett voiced her support for the concept of taxes on sugary drinks but also acknowledged their mixed associations with consumption depending on geographic area, as well as the disproportionate burden of taxation on people with low incomes (although she also noted that these populations are often exposed to disproportionate levels of marketing for such beverages).
Duren reminded participants that tribes, as sovereign governments, retain their own taxation authority, and tribal governments sometimes impose taxes on certain activities that occur within their jurisdictional boundaries, reservation boundaries, or a business in which they are engaged. With respect to economic activity on tribal lands, he continued, tribes provide and finance services for which they do not necessarily have a standard or established tax base because tribal citizens are also citizens of their states and the United States. This situation, he maintained, creates the potential for dual taxation if tribal governments decide to issue taxes on the same services or goods that are taxed by the state and/or federal government. From a tribal perspective, Duren suggested, a federal tax on a particular item or activity would be construed as relinquishing a tribal government’s taxation authority for that item or activity. Tribal stakeholders want to ensure that tribal governments retain authority to make taxation decisions that affect their tribes, he elaborated, and that they receive the tax revenues and determine how to use them for the benefit of their citizens. According to Duren, while tribes may be able to negotiate agreements with state governments to split revenues from excise taxes on certain items or services, this arrangement depends on a tribe’s relationship with its state government.
Benefit Distribution from USDA Funding and Programs
Asked for his opinion on ending farm subsidies, Duren said the IAC does not have a firm stance on this issue, but took a broader perspective to raise the issue of benefit distribution from USDA funding and programs. Noting that the majority of Coronavirus Aid, Relief, and Economic Security Act funding went to White, male, large-scale producers, he appealed for more equitable access to USDA programs. Referring specifically to farm subsidies, he suggested examining what kinds of products are more or less
likely to receive support and considering that degree of likelihood in relation to the characteristics of producers of those products. This perspective reflects a wider lens, he explained, that is oriented to reshaping USDA programs and support structures to better serve all types of producers in today’s landscape and promote the production of foods more aligned with current dietary guidance. An example of such innovation, he continued, is to invest in strong local food structures that lift up both producers—who would never be able to compete in a large-scale food processing market—and consumers in a community.
Issues of Preemption
In Bassett’s view, preemption—when a state passes a law that takes precedence over local law—is a worrying development because it means that innovations in local jurisdictions, which may go further than the state is willing to go, can be rolled back by preemption. The only recourse is legal action to overturn laws that preempt local authority, she said, and she cited preemption along with corporate freedom of speech as two key arguments used to oppose such public health approaches as taxes on sugary drinks and marketing restrictions on unhealthy foods and beverages. Silvera added that this issue relates to voting rights as an upstream determinant of health because eligibility to vote in state elections can influence who is elected to state government and what policies they support, which may relate to preemption.
Tribal governments are similar to local governments, said Duren, in that they want to retain power and authority over the laws that govern their jurisdictions and the people who live there. He reiterated the importance of ensuring representation of the voices of people who will be affected by a policy during the policy development process. Government’s role is to protect public interests, he maintained, and because corporations must operate within the laws passed by the government, changes could be made to those laws to better protect the public.
