August 20, 2012
Health care reform does not start in your kitchen
by Quinn O'Neill
Making the rounds on facebook and twitter is this anonymous quotation: “True health care reform starts in your kitchen, not in Washington.” Where I've seen it posted on facebook, it’s accompanied by a photo of fresh fruits and vegetables and garners enthusiastic and positive responses.
It seems to be widely understood that you can ensure your own good health by eating fresh fruits and vegetables, avoiding junk food, exercising regularly, and not smoking. It’s an empowering idea that places the individual in charge of his own health, but there’s a flip side: if good health is attributable to the healthy choices that we make as individuals, then poor health must also be a choice.
This kind of thinking shapes our views on health care reform. If people choose to smoke, be sedentary, and consume an unhealthy diet, then why should the rest of us be expected to pay for their treatment when they end up with poor health? They made bad choices and so they should suffer the consequences.
The problem with this reasoning is that none of us makes decisions independently of our living conditions, and we have limited control over these conditions. We can’t blame children for learning unhealthy eating habits from their parents and we can’t blame a teenager who starts smoking as a result of peer pressure for being so desperate to fit in. Nor can we blame them for becoming unhealthy adults as a result of this early experience.
The most powerful influences on our health are not a matter of personal choice. They are well known to health care professionals as the "social determinants of health” and, unfortunately, they seem to be a well kept secret. “Health care” continues to be framed in public disourse as a system for providing medical services rather than a system for optimizing health within our society. If we care about health, we ought to be as interested in preventing illness as in treating it.
A 2003 report by the World Health Organization made this distinction clear. It says “Health policy was once thought to be about little more than the provision and funding of medical care: the social determinants of health were discussed only among academics. This is now changing. While medical care can prolong survival and improve prognosis after some serious diseases, more important for the health of the population as a whole are the social and economic conditions that make people ill and in need of medical care in the first place.”
I'm not convinced that the public’s concept of health policy is changing for the better. Poverty and social inequality, which contribute to poor health, continue to grow, while the inaffordability of medical services impoverishes the ill and injured. Meanwhile, our health care professionals dispense their services to those who can afford them without giving much more than lip service to the socioeconomic and political forces behind growing public health problems. Whenever health care reform is discussed, the social determinants of health ought to come up, yet they seldom do.
The WHO report mentioned above provides a very readable overview of these important factors. The determinants themselves, though widely accepted, vary depending on the organization and the given document’s authorship. This WHO report discusses ten factors, but another WHO site describes seven, and a Canadian version lists fourteen. Invariably, some or all of the following are included:
- Poverty/Income/Inome Distribution
- Education
- Physical Environment
- Early Life/Early Childhood Development
- Social Exclusion
- Working conditions
- Unemployment/Job Security
- Social support
- Food Insecurity
- Housing
- Social Safety Network
- Health Services
- Transport
- Addiction
- Stress
- Gender
- Race
- Disability
The variability from one source to another is undoubtedly due to overlap and interrelatedness among the determinants. Poverty, for example, has a strongly detrimental effect on early childhood development and educational level. Adults' educational attainment in turn affects their employment and income, and will shape the early life circumstances of their children.
Many of these factors may also compound to destroy health. The WHO report notes that drug use is a response to social breakdown as well as an important factor in worsening inequalities in health. People may turn to alcohol as a means of coping with difficult socioeconomic circumstances and their alcohol dependence may worsen their situation by resulting in loss of employment, social support, and other requisites for health.
On a positive note, the connections among these factors mean that investment in one area is likely to have positive effects that radiate to other areas. Investing in affordable public transportation, for example, may improve access to grocery stores, social and recreational activities, and health resources. It may also reduce pollution, improve respiratory ailments that are aggravated by pollution, and reduce motor vehicle accidents and associated deaths and disabilities.
Restricting our concept of health care to the provision of medical services limits our power to improve health at the population level. If we want to reduce the need for medical care - and the amount we spend on it - health policy must address the factors that most powerfully determine health.
If we could individually control the social determinants of our own health, we would each choose to be born into a healthy environment to great parents, to be well-off, to have great social support, and to live low-stress lives. We generally can’t choose these conditions for ourselves but we can make choices. Poverty will impair the health of nearly a quarter of American children and stunt their potential to become healthy adults who contribute to society. This isn’t their choice, it’s ours. Collectively, we've chosen to tolerate a political and economic system that promotes social inequality.
True health care reform doesn’t begin in the kitchen; it begins with an understanding that the social conditions that we create collectively affect everyone’s health.
Posted by Quinn O'Neill at 12:05 AM | Permalink
Comments
I made this very point in a recent post at Ratio Juris, which also has a reading list essential to this argument: http://ratiojuris.blogspot.com/2012/08/health-social-justice-inexcusably.html
See too this more extensive collection of relevant literature (up to 2008): http://ratiojuris.blogspot.com/2008/11/health-law-ethics-social-justice-basic.html
Posted by: Patrick S. O'Donnell | Aug 20, 2012 9:39:50 AM
The social determinants of health in the WHO report describe the overall context of our personal lifestyle decisions. But you can't escape the fact that ultimately the decision to eat those potato chips, spend the evening on the couch, or smoke crack is yours and yours alone.
No one shoves a cheeseburger in your mouth. That's your choice. Domestic violence also has social determinants. But none of us is lining up to defend spouse abusers on that account. If we expect people to control their fists in the heat of a domestic argument, we should also expect people to control their fists when those fists are carrying spoonfuls of ice cream.
Raising awareness of personal responsibility appears at first to be blaming the victim. But what is the more achievable goal: Changing the social determinants of health (ending poverty, for instance) or changing self-chosen individual behaviors? Awareness of the social determinants of health should in theory lead to social change, but I wouldn't hold my breath.
The tremendous success of the broad-based stop-smoking campaigns of the past 50 years shows that it is possible to change individual attitudes toward even the most addictive habits.
The "healthcare reform begins in your kitchen" meme is a cost effective approach that needs to be even more widely and decisively communicated.
Posted by: Faze | Aug 20, 2012 1:08:40 PM
Good health starts with curiosity. I noticed early on that some people were healthy and some people were not. I observed the healthy people and the unhealthy people and found that curiosity was a constant with healthy people. Unhealthy people were incurious and even hostile about improved health. I have a better diet than I used to -- historical ignorance is a poor excuse for current ignorance for a dog, a parrot or a human.
Posted by: kirk | Aug 20, 2012 1:31:38 PM
social determinant = susceptibility to being influenced by advertising = lack of education = the alienation of capitalism
Posted by: Kim Cascone | Aug 20, 2012 2:24:07 PM
Faze,
You might want to consider the following:
"A moral viewpoint that puts great store on individual choice and responsibility must offer a criterion for determining which choices incur these obligations. The web of complications that stand in the way is, as we know from criminal law, extremely broad. But in criminal law we have at least a set of precedents and statutory specifications that guide us. In the case of personal responsibility for health, we have only the intuitions of one observer, set against that of another. Moreover, actions only rarely have all the attributes--informed, voluntary, uncoerced, spontaneous, deliberated, etc.--that, in the ideal case, are conditions for full personal responsibility. This is a particular problem in the case of lifestyles, which are matters of habit ingrained over many years and may have been learned from the individual's principal role models.
An examination of the small literature...that has proposed a greater role for personal responsibility reveals that not all choices leading to illness are counted alike. Those that are targeted tend to be sins--sloth, gluttony, lust, to use their old-fashioned names--or to be behavior, such as drug addiction, of the marginalised.
[A] policy in which individuals are made to shoulder the burden caused by adverse consequences of choices they have made must make 'the punishment fit the crime.' The burden re-imposed on the risk-taker should be proportional to the burden imposed by the risk taking. But there is no metric to permit this. One problem is that similar behavior in different people, and in different circumstances, represents quite different levels of risk (Japanese men, for example, are less likely to contract lung cancer from smoking than American men). Moreover, some habits which are unhealthy, even lethal for some are actually health-giving to others; alcohol is the outstanding example. And some habits, because they are taxed, may present a net economic gain to their societies. [....] In this light, proposals to attach importance in health policy to imprudent health-related behavior involve a great deal of hand-waving. A sense of proportion is elusive.
[T]he fostering of a sense of personal responsibility for health can be part of a programmes of 'positive freedom' or 'empowerment,' a realization that actions taken can have a marked and positive impact on one's health, with radiating good effects on other dimensions of life and on other people. There is a risk, in stressing what the individual can do to stay healthy, that an individual's actual power will be exaggerated, and consequently that people can come to blame themselves, wrongfully, when they fall ill. But there is nothing inherent in the prospect of health promotion that necessitates this double message, and there is no reason to hold back from development of techniques of education and motivation which enable those who would favour the tradeoffs required to avoid illness and injury to do so efficiently and confidently. Neither self-blame nor that of others need figure in personal responsibility for health thus conceived.
---Daniel Wikler
The circumstances and conditions of choice make it unreasonable to speak of simply "changing self-chosen behaviors," not only for the some of the reasons noted above, but also for reasons made plain in Raj Patel's Stuffed and Starved: The Hidden Battle for the World Food System (2007), as well as Robert Gottleib and Anupama Joshi's Food Justice (2010).
Posted by: Patrick S. O'Donnell | Aug 20, 2012 2:27:18 PM
Good essay, Quinn! Patrick, thanks as always for Ratio Juris and its phenomenal resources.
When we see middle class people who are educated about the elements of a healthy diet and consistently able to afford the groceries it requires falling ill, we have to look further afield. Maybe they're eating pesticide-imbued correct healthy vegetables and fruits, maybe the toxicity in the general food supply is making even the relatively well-off ill. Especially the children. If you want good health from food, you will buy your produce from a local organic farmer, not from a suburban grocery store where the produce looks nice and fresh but comes coated in carcinogens that won't rinse off. Everything you say, Quinn, is true -- because access to that farmer for many families is a pure fantasy, for all the reasons you cite. Nevertheless, I believe that Big Ag and Monsanto are the forces to reckon with, if they can have even people with money paying for food that cannot endow them with health.
Posted by: Elatia Harris | Aug 20, 2012 2:51:52 PM
Patrick S.O'Donnell:
Thank you for your reply. "A sense of proportion" may be "elusive" as you suggest, and there is always the potential of moralizing or further marginalizing the already marginal. But there is no exaggerating people's actual control over their own choices -- as the millions of who have successfully overcome fearsome addictions can testify.
In overcoming these addictions, a nuanced approach to one's own behavior is rarely successful. The first step is always to stop doing the addictive behavior. Arranging the rest of your life with all its subtleties, class realities and racial and ethnic particularities comes second.
Why should anyone deny the agency of others over the own behavior? Health is a status indicator. High status people may feel threatened by the prospect of a proletariat rendered hale and healthy by its own exertions rather than the paternalistic "care" of the medical establishment. One way to assure that low status people stay low status is to reinforce the belief that they are powerless to make improvements in their own life.
We should beware of adopting a colonialist mentality. We should celebrate the potential for each individual to prevent illness before it happens and rob the establishment of power over our bodies.
Posted by: Faze | Aug 20, 2012 4:09:29 PM
Faze, you don't get poverty, you don't get food systems, and you'll do best going back to the books and learning something useful. Raj Patel and Vandana Shiva are where you need to start. A new understanding of the world awaits you, once you take off the pith helmet. You might see your own choices and your own personal responsibilities as expanded, and be less concerned with forcing purely mythical choices on others.
Posted by: Elatia Harris | Aug 20, 2012 5:11:22 PM
One last comment by way of reply: nothing whatsoever was said by anyone that was intended to deny the capacity for and the exercise of agency, the point rather being (as Amartya Sen, among others, would remind us) the various factors that render the exercise of the agency of some more "free" than others: personal heterogeneities or contingincies that render us unequal in the exercise of whatever freedom, metaphysically or existentially, ontologically, morally, or psychologically we possess. Thus, there are differences, for example and by way of illustration (hence not exhaustive) with regard to physical characteristics having to do with age, gender, disability, proneness to illness; diversities in the physical environment (both ecological and geopolitical); variations in the social climate with regard to public health and epidemiology, public education, the prevalence or absence of crime and violence, the nature of community relations; differences in relations perspectives owing to established patterns of behaviour, often owing to intransigent or opaque social norms, etc.
Nor does anyone I cite (nor do I) believe that what they are proposing in any way contributes to reinforcement of a putative belief that the powerless must remain so. Of course sometimes the belief that one is powerless is owing to the adaptation to situations and circumstances such that the disenfranchised or oppressed express "contentment" of a kind with their circumstances, being more or less resigned to their lot. As Sen and others have explained, such adjustment to circumstances helps to make life bearable in adverse situations: "The hopelessly deprived people may lack the courage to desire any radical change and typically tend to adjust their desires and expecatations to what little they see as feasible. They train themselves to take pleasures in small mercies." However understandable, such adjustments to chronically adverse circumstances or conditions results in expectations and perceptions that perpetuate social inequalities and manifest differences in the capacity to realize effective exercise of free agency (thus agency freedom, possessed in principle, is not the same thing as or does not always guarantee the optimal realization of, agency achievement, well-being achievement, or well-being freedom).
It is, in other words, no easy task, nor does everyone equally face the same sort of task, when it comes to changing one's behavior. For example, "women who are systematically oppressed may not have strong preferences for individual liberties, the very liberties that may help improve their health: the same wages or educational opportunities as men, or even protection from domestic violence. So if we are going to talk about the exercise of free agency we must be sensitive to the "ways in which habit, fear, low expectiations, and unjust background conditions deform people's choices and even their wishes for their own lives" (Martha Nussbaum). Put differently, this time by Robert Goodin: "people sometimes make their choices on the basis of incomplete information, in ignorance of their own future desires or even in the absence of full and vivid awareness of all the alternatives; other times, people's choices merely reflect the framework in which they are set or a desire to avoid responsibility." In these cases, it is no easy matter for some people to learn what it means to possess the power to prevent illness or to appreciate what capacity for the exercise of power they may possess or come to possess, given a change in their socio-economic and political condition. In short, we should give due recognition and accord due sensitivity to the myriad manifest differences in "people's actual control over their own choices," differences that are all too easily neglected, ignored, rationalized, forgotten, and so on such that we can in fact, it would seem, readily exaggerate the nature of such control.
Posted by: Patrick S. O'Donnell | Aug 20, 2012 5:27:44 PM
Yay Patrick!
Posted by: Elatia Harris | Aug 20, 2012 6:06:24 PM
So we're basically hosed.
If we leave nutrition and health up to individuals then that will surely fail. We have hundreds of years of data to assure us of this. Whether it is a failure of will or poor conditions we don't have to worry over. The end result is some people demand their bacon and eggs and fried potatoes. Yum!
The alternative is what? We're supposed to be led along some path toward centralized control of our diet and health. It won't be shoved down our collective throats all at once, but slowly so that we can all pretend we had something to do with it and it was our decision after all.
You want bacon and eggs and fried potatoes? Go ahead, but there will be an added tax on every gram of fat.
How about some nice fresh broccoli? Why it just so happens that's subsidized by those taxes on bacon and eggs! Lucky for you!
And you decided! With your votes for specific pieces of legislation or for the people that voted in those pieces of legislation; legislation that neither you nor your elected representative ever bothered to read. How democratic of us all!
Oh, and similarly we will end poverty, poor housing, poor education, and waiting lines for dodgy health care by extending all of the ongoing centralizing efforts that have achieved such great results to date.
I believe there are some wonderful resources I can recommend to support these efforts: Utopia, Brave New World, 1984, The Road to Serfdom, etc.
Posted by: DAS | Aug 20, 2012 10:26:39 PM
No one shoves a cheeseburger in your mouth.
Some people have no choice! It is exactly as Quinn describes. Several socio-economic factors are at play in this case and the government is hand in glove with large retail grocers. On the other hand, I agree with DAS that it is impossible to legislate good habits or tax bad ones. But surely, it can encourage healthy habits through education, improving school lunches and not dumping junk food on the poor.
Posted by: Ruchira | Aug 21, 2012 12:57:17 AM
I agree with a large part of what Quinn and Patrick etc say about social determinants, but it also feels like Faze is on to something.
For me, an important distinction to draw is that between what causes a problem and how you might go about solving it. It's not the case that the only proper way of solving a problem is redressing the causes. The causes of poor vision are many, genetics and poor diet and bad reading habits and so on. But the solutions we've hit upon (adequate vitamins, eyeglasses, surgery) completely ignore one of the causes (genetics), and are in fact largely based on a palliative (glasses). So too, when dealing with obesity, we mustn't assume that the proper way to solve the problem is to eliminate all the causes. This is true whether you're focused on proximate causes like calorie balance (like Faze) or underlying socioeconomic conditions (as for others here).
And we had better hope Faze isn't -completely- wrong about reaching people again to make them exercise more, eat better food and so on. Because if solving obesity means improving first "Poverty/Income/Inome Distribution, Education, Physical Environment, Early Life/Early Childhood Development, Social Exclusion, Working conditions, Unemployment/Job Security, Social support, Food Insecurity, Housing, Social Safety Network, Health Services, Transport, Addiction, Stress, Gender, Race and Disability" well, people will keep growing blimpier forever.
I do think in fact that educating people about nutrition, and encouraging better habits through policy and social pressure is both important and feasible. To be sure, for example, that there are 'food deserts' so not everyone can get access to good food. There are probably limits to how well obesity can be tackled while that's the case. But I'm also pretty sure there's hardly anyone in a first world country who has such poor access to clean fluids that he needs to consume 216 liters of soda a year (the US average; in Japan it's 21 liters). People -learned- how to feel uncool while smoking. Nor is policy just about fixing social causes or stressing personal responsibility. It's also about taxation and subsidy. However bad social networks are, there's no obvious reason not to reconsider corn subsidy (by which I mean get rid of it). Meanwhile, I really do hope obesity doesn't have to "wait in the pipeline" for race and gender to get solved first! Finally, I quite like the eyeglasses example. Why are we moralizing these problems so much, trying only to fix -defects- in people, in society, in policy etc? Maybe Splenda is the way to go! Why is the spending on research into zero-calorie oils (for example) so small?
Posted by: prasad | Aug 21, 2012 5:23:41 AM
A final point on obesity: for a pretty decent chunk of the population, I think aesthetics and health come apart. Being obese is really bad for health, but it turns out being overweight versus not has pretty minimal health impact (effects going both ways). Having a BMI of 21 versus 27 probably doesn't matter much with respect to health impact.
Posted by: prasad | Aug 21, 2012 5:36:18 AM
For the record, I did not deny the Faze had a point, hence my use of the material from Wikler, which ended as follows:
"There is a risk, in stressing what the individual can do to stay healthy, that an individual's actual power will be exaggerated, and consequently that people can come to blame themselves, wrongfully, when they fall ill. But there is nothing inherent in the prospect of health promotion that necessitates this double message, and there is no reason to hold back from development of techniques of education and motivation which enable those who would favour the tradeoffs required to avoid illness and injury to do so efficiently and confidently. Neither self-blame nor that of others need figure in personal responsibility for health thus conceived."
This is a clear affirmation of a role for encouraging the assumption (properly qualified and understood) of personal responsibility: "...there is no reason to hold back from development of techniques of education and motivation...."
Posted by: Patrick S. O'Donnell | Aug 21, 2012 8:55:03 AM
Keep in mind that we are "responsible" for our health in the face of overwhelming promotion and advertising of patently unhealthy foods and those foods in ridiculously large portions. We only have so much control over our imaginations, I'm afraid. Notice that grocery stores are filled to overflowing with Big Agra products and processed foods of every kind. How do you resist this? It's human nature to give in and the food industry (and the propagandists) know this.
There is also a pervasive system of ridicule and insult in place, at the ready to persecute those of us who choose better food and exercise. It's a culture-wide point of ridicule.
When I was heavy and gluttonous, no one ever said anything to me about my girth and they in fact praised my large appetite. When I lost weight and began exercising, I became a target of constant ridicule and insult, from the time "wasted" to the appearance of my exercise clothes to my baffling habit of walking and bicycling. The propaganda industry assures that those who don't comply with gluttony and sloth are ridiculed.
Posted by: Ray Butlers | Aug 21, 2012 10:15:11 AM
The subject of health and illness (i.e., the optimal functioning of the body/mind) is certainly complex. What irks me is folks who want to advance a drastically simplified theory about it. For example: "It's all due to incorrect eating habits; just follow the diet I recommend and all your problems will be solved." Or: "It's all due to the evil effects of monopoly capitalism; just overthrow the system and establish the utopian system I advocate, and everyone will be in perfect health ever after." Or: "If everyone just used the ancient, proven system of Druidic medicine I am promoting (click this link for an order blank to get my 50-page pamphlet on the subject for a small fee), they could cure themselves of whatever ails them, cross my heart. Curses on 'modern, scientific medicine!'"
The sad truth, I am afraid, is that the structure and physiology of the human body/mind is extremely complex, and the ways in which it can malfunction, and the causes of those malfunctions, are too numerous to count. There are correspondingly many ways of attacking illness, and they all need to be employed. Go ahead: encourage everyone to eat fresh veggies and boycott fast-food restaurants. Abolish capitalism. Take your herbs and mineral supplements (but watch the overdoses; those "natural substances" can be toxic, too). Even "modern scientific medicine," so often derided and sneered at, has its uses. The next time you have a heart attack, try swallowing a few herbs and sending a contribution to your favorite political action group as you expire, rather than calling 911 to give the modern scientific doctors a crack at you.
This is admittedly an extreme example, but I personally have gotten a lot of benefit from the dastardly, rotten doctors (and even the dastardly, rotten pharmaceutical companies) whom everyone loves to condemn. The problem, in the U.S. especially, is that their services can be quite expensive, which is why I hope we get to a single-payer system, like those of the rest of the world, as soon as possible.
Posted by: JonJ | Aug 21, 2012 10:19:22 AM
Look, this one's simple. At the level of policy, O'Neill is right. Of course, from the top-down, macro perspective, fixing health care involved taking social determinants as primary elements.
However, O'Neill is flat-out wrong when she says that we cannot hold people responsible for their choices. Quinn: stick to the policy level and your conclusions follow nicely, but do not embroil yourself in debates at different levels. From the perspective of the individual, social determinants cannot eradicate responsibility, or there is no responsibility for anything at all. We must be able to say both (1) that persons are responsible/blame-able for making poor decisions when they have options, and (2) that policy-makers must focus on macro-level determinants without concerning themselves with individual responsibility. Keeping these two issues seperate makes by far the most sense.
Posted by: Joe | Aug 21, 2012 11:00:23 AM
The Environmental Working Group has just published a free resource for shopping well and eating well while keeping your food bill down. Please visit their site.
http://www.ewg.org/goodfood/
And then, tell me how easy it would be for people who live in a food desert to make this happen for themselves. Not everyone with a lousy address and a very low income is an idiot about food, too. Homeless people are not uninformed about what's good and what's not, either. As anyone who has ever fed the homeless has observed, they crave fresh greens more than anything.
Everybody upstream with libertarian leanings is not wrong about the importance of choice, but I believe they are exalting it above other factors that are stronger, in this particular situation. Better to work for food justice than to ask every low income family to smarten up and make choices you can, from your perch, respect? What do you think?
Posted by: Elatia Harris | Aug 21, 2012 11:17:43 AM
Why no mention of genes? One of the most important determinants of good or bad health.
Posted by: Mimi | Aug 21, 2012 2:07:09 PM
all the verbiage above can be boiled down to the fact that TV and other forms of advertising hypnotize the public into adopting behaviors that enables a corporation to profit...simple, they profit from a choice of fast food, then resulting illnesses and finally your death. Not to sound conspiratorial but eating well is your best defense against the hypnotic brainwashing of media. Watch the doc: "Forks Over Knives" for a good overview.
http://www.hulu.com/watch/279734
Posted by: Kim Cascone | Aug 21, 2012 3:20:18 PM
I'm reminded of a CBC documentary that Wendy Mesley did about her own battle with breast cancer and her investigation of the environmental causes of cancer. She observed that she had done everything right - ate the right foods, exercised, etc. - and yet she still became ill. The emphasis from many advisory sources has been on individual responsibility, and, lacking the balance of a proper attention to environmental, systemic causes beyond individual control (pollution, pesticides, herbicides, xenoestrogenic compounds that have proliferated since WW II with the growth of the chemical and plastics industries, etc.), the effect is a subtle "blame the victim" message.
Posted by: Kai Matthews | Aug 25, 2012 9:57:32 AM
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