The typical public health observational study goes something like this. We identify a disease of interest. We then try to figure out if an exposure is indeed associated with this disease. We conduct a study and collect data from participants. We then use a variety of increasingly sophisticated analytic tools to isolate the relationship between the exposure of interest and the disease. Once we have identified such an association with some confidence, we recommend a behavior change that will limit exposure to that particular factor. For example, here is the conclusion from a recent, well done study aimed at understanding several factors that may cause cardiovascular disease: “strategies should focus on reducing obesity, in particular through physical activity, elimination of cigarette smoking, and moderation of alcohol intake” (1).
In other words, to reduce heart disease, we need a lifestyle change, to eat less, exercise more, and smoke less, in order to become healthier. These types of conclusions come from peer-reviewed academic papers published in reputable public health journals. In many ways, these recommendations arise naturally and logically from the dominant public health paradigm. We understand the factors that make us sick and now all we have to do is to change the way we live so that we are no longer exposed to those factors.
Although it is seldom stated in this manner, the public health literature veritably shrugs in disbelief when contemplating these issues, suggesting “how could they possibly keep smoking (or drinking too much etc) when we tell them over and over how bad that is for their health?” Or, “how could they possibly continue having such an unhealthy lifestyle?”
Tobacco as a Lifestyle Problem
Let’s look back at one of the great triumphs of modern public health science to provide us with hints about our lifestyle and whether we truly can do something about it. All students of public health well know the details of what the Centers for Disease Control and Prevention (CDC) rightly identified as modern pubic health’s greatest triumph—the identification of tobacco smoking as a risk for disease(2). In the middle of the twentieth century a few physicians-turned-epidemiologists used follow-up cohort studies to show that cigarette smoking was associated with lung cancer and heart disease. These studies led to other comparable studies confirming these findings. There was opposition to this observation at first, primarily from cigarette companies, but, with the production of the surgeon general’s report on smoking in 1964, the fact that smoking causes poor health in many forms became accepted within public health circles. What followed of course was a dramatic burgeoning public health effort to help eliminate smoking. A large industry grew around health education programs to teach all of us about the adverse consequences of smoking and countless education programs aimed to help smokers quit.
Smoking prevalence dropped throughout North America from 42% in 1965 to 25.5% in 1990 to a current prevalence of approximately 20.8% percent (3).
Clearly, public health research and practice “saved the day”. Through careful empiric research, we were able to identify a health menace and we have, ever since, been devoting energy to help eradicate this menace. One cannot walk through any major US urban area without seeing a plethora of health education messages touting the evils of smoking, offering Quit-Lines and other aides to quite smoking and, increasingly, rather horrifying pictures of the pathologic consequences of smoking aimed at scaring us into not smoking.
But we, or at least 1 in every 5 of us, keep smoking. In fact, we keep participating in many of these factors that we surely must by now know cause poor health, including 1 in 5 of us drink too much on a regular basis, 1 in 3 of us are overweight, and 1 in 3 of us own firearms (4). All of these factors are well recognized to be among the leading causes of death in this country (5).
Why do people choose unhealthy lifestyles?
Which then brings us to the issue at hand. Why is it that so many patently harmful factors in our lifestyle continue despite public health’s valiant effort? The existing literature suggests three common answers. First, some posit that there are psychological reasons, including pleasure in risk taking and defying conventional wisdom, in continuing to embrace unhealthy lifestyles. Second, some argue that public health professionals are not as good as we need to be at conveying what unhealthy lifestyles should be avoided. A third explanation asserts that ultimately people do not care much about being healthy and would rather do as they please without regard for health. All these can be summarized to say that fundamentally, people choose the lifestyle they want, irrespective of what public health might say.
While these (and other) explanations all have some validity, they should matter little to us as public health professionals because a focus on lifestyle is simply not the most efficient or effective approach for public health to take. Why?
Perhaps another example, one that contrasts with the previous smoking one, illustrates the point. Another of the CDC’s great recent achievements in public health is the reduction in motor vehicle injuries and deaths (2). As the automobile took the US by storm by the middle of the twentieth century, the rates of motor vehicle accidents and deaths were soaring. There were 93,803 unintentional motor vehicle related deaths in 1960, for example (5). Clearly, our lifestyle choice to drive was also killing us. One approach would have been for the public health establishment to urge every American to drive less, to walk instead or take mass transit – to change their transportation life style. But that is not what happened.
Instead, a consumer movement emerged that demanded the automobile industry to make safer cars and Congress passed laws to make that happen, usually over the objection of the automobile industry and with significant compromises. For example, Ralph Nader’s Unsafe at any speed (1965) resulted in changes that substantially changed the contribution of motor vehicle accidents to our burden of disease morbidity and mortality. However, in stark contrast to the tobacco example, the focus of the changes aimed at reducing car-related disease was not on the “users” of the car but rather on the circumstances of the driving. Certainly driver education improved, but it is widely recognized that the greatest contributor to the change in car-related morbidity and mortality were safer cars, safer roads and better enforcement of traffic regulations aimed at making those collisions that were inevitable less injurious. As a result, although there are now more than 200 million drivers on the roads on a regular basis, compared to under 90 million in 1960, the rates of motor vehicle accidents in the US is less than 1.5 per 100 million vehicle miles traveled compared to approximately 5 per 100 million vehicle miles traveled in 1960 (6, 7). In other words, we did not really change our lifestyle (driving) at all (in fact, we are driving much more than ever), but still improved our health. We can argue about whether a different approach might have led to more sustainable and better environmental outcomes, but in this case changing corporate practices rather than lifestyle led to dramatic improvements in public health.
In contrast, until the last decade or so, tobacco control focused primarily on changing individual behavior. As new policies were passed to ban smoking in public places and increase tobacco sales taxes, the declines in tobacco smoking accelerated, showing the value of integrating strategies to change individual lifestyle and policy.
Both these examples in fact reinforce the observation that changing lifestyles is immeasurably difficult, requiring not only efforts to change deeply held beliefs and practices one person at a time but also to continue to “treat” the new recruits into tobacco use, or eating or drinking too much. Thus, perhaps changing lifestyles should not be the point of what we do in public health but rather changing circumstances should be. Perhaps it is time to recognize that changing lifestyles is in fact very difficult and that a more efficient and effective approach would be to change the political, economic, and social circumstances within which people live their life as they please, to the fullest. This strategy also acknowledges that people do not choose lifestyles in a vacuum but are influenced by corporate practices such as advertising and product design, by public policies, and by the “opportunity structures” of our market economy.
Objections to a critique of lifestyle
This argument can lead to complaints along three grounds. First, some would object to leaving individuals to their own lifestyle choices within a healthier environment as insufficient given that some lifestyles are inherently injurious to self or others. Second, some critics might assert that if public health were to take responsibility for the circumstances within which we live, it would contribute to a “nanny state”, highly unpopular in a country where individual autonomy is prized almost above all other virtues. Third, some public health experts believe that it is outside our professional domain to seek to change economic, political, and social circumstances. In my view, each of these criticisms is in fact wrong. Let us tackle each one.
We cannot avoid dealing with lifestyles; some lifestyles are always harmful. It may seem that some lifestyles are simply harmful in an absolute sense, but is this really the case? Let’s return to the cigarette example. We now know that tobacco companies worked hard to make cigarettes more addictive to increase consumption and therefore profit. From the point of view of addictiveness and carcinogenicity, they are harmful by design. To take another example, people choose high fat, high calorie food in part because that is what has been most advertised and made most available. In these two cases, the health consequences of lifestyle “choices” are the direct result of efforts to make a profit. With different food or tobacco policies, the default choices could be very different. So what do public health professionals work to change—the environments and policies that make some lifestyle choices unhealthy or the behaviors themselves?
Public health cannot tackle political, economic, or social circumstances because that threatens individual autonomy. Would a public health focus on changing the circumstances within which we live mean that public health would reduce individual autonomy? Of course it could but the critical point is that doing so would not be any different than what is already done to our individual autonomy by forces other than public health. We do not choose the cigarettes we smoke—we smoke cigarettes that are made for us by corporations acting under a set of their own incentives (primarily to maximize profits) that are often not aligned with the goal of improving our health. We often have little choice about the food we eat. Recent research shows that those living in poor neighborhoods have more access to unhealthy foods and less to healthy ones. Not surprisingly, they then eat those available foods. Similarly, for the most part drivers do not choose to drive in safer cars, on safer roads than we used to drive on 50 years ago. These choices are made for us by political, economic, and social forces that are larger than ourselves. It has always been so and it will always be so. Urging public health to tackle reshaping our circumstances would introduce a player among these forces that shape our circumstances whose interest is in the promotion of health rather than in the promotion of profit (as in the case of corporations) or electoral success (as in the case of political parties). The choice is not whether parents should have sole rights to make health decisions about their children – our world is too complicated for that. Rather, the question is who do Americans want looking out for their children’s health—public health professionals or McDonalds? Public health professionals should welcome an opportunity to argue they will better protect autonomy than Ronald McDonald.
Public health simply is not equipped to tackle changing contexts. This third objection is a plaintive one—but what can public health do? Public health arises from medicine, which is concerned with the health of individuals. The forces of public health are much weaker than are political, economic, or social forces. How could we possibly compete? It is self-evident that unless we try to compete we cannot succeed. It is also true that challenging contextual forces that shape health as a central focus would require substantial retooling of the public health profession. It would require re-thinking how we teach our students, the goals and methods of professional practice, and the value of being well-regarded by all sectors of society. But other professions have been able to conduct similar retooling. Why then not public health? For example, many US State Attorneys General were, in the 1970s and 1980s focused on the eradication of organized crime. This scarcely remains the focus on AG efforts nationwide today. In fact, AG efforts have been, in the past decade, much more focused on curtailing illegal financial sector activity than on what the AG offices used to work on a decade ago. Surely such focus shifting could not have been easy. But it happened, and arguably the law-abiding citizenry is better for it.
Another approach to public health is possible
Similarly, public health can decide that the old target, lifestyle, is no longer, or perhaps never was, such a fruitful target for our efforts, and move toward another target, the circumstances within which we live, the political, economic, and corporate practices that shape our environment, with the goals of effecting change here in order to promote the health of the public. The objections to such an approach rest primarily on a lack of imagination on our part that we can indeed achieve a change in focus in the profession. I argue that such a change is not optional, as much as necessary, for public health achievement in the twenty-first century.
Sandro Galea is the editor of Macrosocial Determinants of Health (Springer 2007) and can be reached at email@example.com.
1. Costanza MK, Cayanis E, Ross BM, Flaherty MS, Alvin GB, Das K, Morabia A. Relative contributions of genes, environments, and interactions to blood lipid concentrations in adult populations. American Journal of Epidemiology2005;161(8):714-724.
2. CDC. Ten great public health achievements–United States, 1900-1999. MMWR 1999;48:241-3.
3. CDC. Surveillance for Selected Tobacco-Use Behaviors — United States, 1900-1994. MMWR 1994; 43: 5-6.
4. Mokdad AH, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-45.
5. Okoro et al. Prevalence of household firearms and firearm-storage practices in the 50 states and the District of Columbia: findings from the Behavioral Risk Factor Surveillance System, 2002. Pediatrics. 2005;166(3):e370-e376
6. CDC. Achievements in Public Health, 1900-1999 Motor-Vehicle Safety: A 20th Century Public Health Achievement. MMWR 1999; 48(18);369-374.
7. Fatality Analysis Reporting System. Encyclopedia. Available at http://www-fars.nhtsa.dot.gov/Main/index.aspx