Commentary: Shifting priorities in public health: from changing lifestyles to changing political, economic, and social circumstances

Posted on by Corporations and Health Watch

Public health researchers seeking to focus greater attention on the role of corporate practices in health and disease often encounter the argument that the only significant modifiable determinant of health is lifestyle.  In this commentary, social epidemiologist Sandro Galea, MD, DrPH, Associate Professor at the University of Michigan School of Public Health makes the case for a broader perspective.

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 sgalea@umich.edu.

 

References

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

 
 

Youth-Involved Street Survey of Health Enhancing and Health Damaging Messages in Disparate Urban Neighborhoods Using Digital Technology

Posted on by Corporations and Health Watch

Neighborhood environments can both promote health (Ewing 2005) and encourage disease (Satterthwaite 1993). Differences in presence of health enhancing and health damaging messages and environments may account for some differences in health among neighborhoods with different socioeconomic and racial/ethnic characteristics (Kipke et al. 2007; Macdonald, Cummins, and Macintyre 2007; Pasch et al. 2007; Snyder et al. 2006; Stafford and Marmot 2003). In this pilot study, our hypothesis is that health-enhancing messages are more prevalent in wealthier neighborhoods and health damaging ones more prevalent in economically impoverished neighborhoods.   For the purposes of this pilot study, we define “health enhancing” messages as messages which promote the consumption of whole grains, fresh fruit and vegetables, low fat dairy and meats or public health service advertisements (e.g., a smoking cessation ad) and “health damaging” as advertisements for alcohol, tobacco and high fat, low nutrient foods.  In preparation for a larger scale study, our goal here was to test a methodology for comparing such messages across communities with differing sociodemographic and environmental characteristics


Disparate Urban Neighborhoods: Upper East Side, East Harlem

To carry out this study, we involved youth researchers in measuring the health enhancing and health damaging messages in two, disparate urban neighborhoods: the affluent and predominantly white Upper East Side of Manhattan, and the neighboring but economically impoverished and predominantly Black and Latino East Harlem. Lexington Avenue, a major thoroughfare, runs through both neighborhoods.    The youth researchers worked in two phases measuring health enhancing and health damaging messages along Lexington Avenue in the two neighborhoods.  The first phase included a class of thirty-three Hunter College undergraduate students; the second phase, a smaller group of three high-school-aged students recruited from Global Kids, a community-based youth organization.   In each phase, the youth surveyed ten block segments of Lexington Avenue in the two neighborhoods.

Using Digital Technology to Measure Health Enhancing and Health Damaging Messages

Researchers at Hunter College partnered with the Fund for the City of New York (FCNY), a nonprofit research and policy group, to modify their ComNET software to measure health enhancing or damaging messages.  FCNY developed the ComNET software to document problems in the urban environment and engage community members in notifying the responsible municipal agencies to address those problems in the urban environment.  ComNET is designed for use on handheld digital devices, equipped with digital cameras.  The use of ComNET and digital technology made this project possible and offered a number of advantages.

First, the handheld devices serve as an important incentive for the engaging the youth.  Young people, most of whom have grown up immersed in digital technologies, quickly learn how to manipulate the devices and yet still see them as fun, innovative “toys.”    It would be much more difficult to engage youth in this research without the use of digital technology.   Second, the ability to quickly upload the data and have it almost immediately available for data cleaning and analysis is an invaluable asset of working with the ComNET software.   The decade-long development of the technology by FCNY and the infrastructure that they have in place to ensure the smooth functioning of the devices, upload, cleaning and analysis of the data, provided a strong foundation for the methodology used here and obviated the research group from investing time and money in developing such a technology.

Findings

The hypothesis that health enhancing messages are more prevalent in better off neighborhoods and health damaging ones more prevalent in poorer neighborhoods appears to be supported by the data from our pilot study. Table and Figure 1 shows that in the 10-block segment our project surveyed, the percentage of health harming ads in East Harlem is 29% greater than in the Upper East Side.  East Harlem also contains nearly 10% fewer health promoting ads than does the Upper East Side.  Both neighborhoods have a higher concentration of health harming than health promoting advertisements.  Tables 2 and 3 illustrate that tobacco and alcohol advertisements are more prevalent in East Harlem than in the Upper East Side where health-harming ads tend to be food-related.

For access to charts/graphs, please access pdf here

Limitations 

The findings here are necessarily limited because this was a pilot study.  First, the sample size (ten block segments measured by two groups) was too small to confidently generalize to all urban areas, all New York City, or even the two neighborhoods studied here.   Further limitations include some challenges with digital technology.  The ComNET software is very effective at measuring some types of problems in the urban environment, but needs further modification to accurately and efficiently measure health enhancing and health damaging messages. Specifically, the addition of a feature that would allow for multiple features for one entry would speed up the process considerably. The limitations of this admittedly small and suggestive pilot study can be addressed in a larger and more systematic follow-up study.

Conclusion

New York City neighborhoods of East Harlem and the Upper East Side represent stark disparities in income, racial composition and health outcomes.  This pilot study examined one aspect of the disparities between these neighborhoods that may contribute to unequal health outcomes: health promoting and health damaging messages.   In general, we found that East Harlem has more ads (of all kinds), more health harming ads, and fewer health-promoting ads than the Upper East Side.     And, we also found that both neighborhoods have more health harming ads than health promoting.   While the presence of health damaging ads cannot account for all the negative health outcomes in a particular urban neighborhood, the disproportionate display of the health damaging ads in East Harlem as compared to the Upper East Side, suggests that some New York City residents bear a greater burden of these messages.  The disparity in the types of health ads that city residents in different neighborhoods are exposed to is a subject that demands further study.  In addition, our pilot study demonstrates that young people can be engaged in studies to document the health characteristics of their communities, an activity that can be a first step in analysis of differences in health and action to reduce inequities in health.

References

Ewing, R. 2005. Building environment to promote health. J Epidemiol Community Health 59 (7):536-7.

Kipke, M.D., E. Iverson, D. Moore, C. Booker, V. Ruelas, A.L. Peters, and F. Kaufman. 2007. Food and park environments: neighborhood-level risks for childhood obesity in East Los Angeles. J Adolesc Health 40 (4):325-33.

Macdonald, L., S. Cummins, and S. Macintyre. 2007. Neighbourhood fast food environment and area deprivation-substitution or concentration? Appetite 29 (1):251-4.

Pasch, K.E. , K.A.  Komro, C.L. Perry, M.O.  Hearst, and K. Farbakhsh. 2007. Outdoor alcohol advertising near schools: what does it advertise and how is it related to intentions and use of alcohol among young adolescents? . J Stud Alcohol Drugs68 (4):587-96.

Satterthwaite, D. 1993. The impact on health of urban environments. Environ Urban 5 (2):87-111.

Snyder, L. , F.  Milici, M.  Slater, H.  Sun, and Y. Strizhakova. 2006. Effects of alcohol exposure on youth drinking. Archives of pediatrics and adolescent medicine 160 (1):18-24.

Stafford, M., and M. Marmot. 2003. Neighbourhood deprivation and health: does it affect us all equally? Int J Epidemiol 32 (3):357-66.

 

For more information on this study contact Jessie Daniels at jdaniels@hunter.cuny.edu

Books on Corporations and Health, 2007

Posted on by Corporations and Health Watch

With thousands of new books published each year, it’s hard to find titles of interest. To help readers sort through the piles, we present an idiosyncratic list of 10 books published in 2007 (or early 2008) that address the relationships among corporations, markets, government and health. These books may help Corporations and Health Watch readers to understand better the impact of corporate practices on health, to occupy cold winter nights, or to pick a gift for a deserving friend. We invite you to submit titles of other books you suggest, limiting titles to those published in 2007.


Ten Titles on Corporations and Health

Benjamin R. Barber. Consumed How Markets Corrupt Children, Infantilize adults, and Swallow Citizens Whole. W.W. Norton and Company, New York, 2007. Political theorist argues over-production of goods forces markets to infantilize consumers and undermine democracy.

Allan M. Brandt. The Cigarette Century The Rise, Fall and Deadly Persistence of the Product that Defined America. Basic Books, New York, 2007. Medical historian analyzes impact of tobacco industry on US and global health and politics.

Jillian Clare Cohen, Patricia Illingworth , & Udo Schuklenk, editors. The Power of Pills: Social, Ethical and Legal Issues in Drug Development, Marketing and Pricing. Pluto Press, London, England, 2007. Three academics edited this interdisciplinary collection of essays that analyze and critique the global pharmaceutical industry.

Philip J. Cook. Paying the Tab The Costs and Benefits of Alcohols Control. Princeton University Press, Princeton, NJ, 2007. Economist analyzes US alcohol policy and suggests increasing taxes to reduce harm.

Devra Davis. The Secret History of the War on Cancer. New York, Basic Books, 2007. Toxicologist describes how industry shapes US response to cancer at expense of prevention.

Richard Feldman. Ricochet Confessions of a Gun Lobbyist. Hoboken, N.J., John Wiley and Son, 2008. Former NRA lobbyist describes how group “betrays trust” of gun supporters.

David Harsanyi. Nanny State: How Food Fascists, Teetotaling Do-Gooders, Priggish Moralists, and other Boneheaded Bureaucrats Are Turning America into a Nation of Children. Broadway, New York, 2007. Libertarian columnist for the Denver Post rants against government interference on health.

Tim McCarthy. Auto Mania Cars, Consumers and the Environment. Yale University Press, New Haven, CT, 2007. Historian describes how auto industry transformed United States in the twentieth century.

Michael Pollan. In Defense of Food: An Eater’s Manifesto. Penguin, New York, 2008. Food journalist suggests actions that individuals, communities and policy makers can take to reclaim food from industrial producers.

Robert B. Reich. Supercapitalism. The Transformation of Business, Democracy, and Everyday Life. Alfred A. Knopf, New York, 2007. Policy analyst and former Clinton Labor Secretary argues that new global competitive pressures force business to serve investors and consumers at expense of society and suggests public policies to restore democratic control of markets.