It’s Not My Fault

I am easily the least health conscious person I know. Almost everything I eat is drenched in mozzarella cheese or coated in a thick layer of sugary goo. I abhor vegetables, have visited the gym a grand total of three (OK, two) times since joining more than a year ago and only recently kicked a 15-year cigarette addiction. Despite having excellent health insurance, I almost never go to the doctor. So if the shooting pain I sometimes feel in my chest turns out to be a clogged artery, and if I only discover this when I am mid–heart attack, I will have no one to blame but myself.

But are people like me responsible for our nation's soaring health-care costs? Anyone who has followed the news lately knows how big and sobering the numbers are: 133 million people or about half of all Americans live with at least one chronic condition; costing us nearly $2 trillion in medical care or 15 percent of our GDP. But reforming health insurance—as the president and Congress are trying to do—is only part of the solution. To really drive those numbers down we'll have to prevent people from getting sick in the first place. So far the primary target for this goal has been human behavior, a strategy that presumes most Americans are like me: they have all the tools needed to live healthy, disease-free lives but because of laziness, selfishness or both, choose not to employ them. If more Americans could get themselves to the gym, the vegetable aisle, and the doctor's office, maybe we could dig ourselves out of this mess.

Is that really true? Sort of. If I develop diabetes or cancer or cardiovascular disease, I will undoubtedly add to the nation's health-care burden. But my behavior is only one in a host of factors that will determine whether any or all of those conditions eventually befall me. In fact, a rapidly growing body of evidence indicates that how much education, income, and social status people have, what's advertised on the billboards or sold in the stores around them, and how clean the air they breathe and streets they walk on are kept, have as much to do with their health as diet, exercise, and doctor's appointments. "It's the context of people's lives that determines their health," says a recent World Health Organization report on health disparities. "So blaming individuals for poor health or crediting them for good health is inappropriate."

Consider the most oft-cited source of our national health-care woes: type II diabetes, triggered by obesity. My food choices alone should make me a prime candidate for both. But I am 5'3" and I have never weighed more than 105 lbs. I'd like to take credit for showing restraint at the pastry shop, but the truth is, I have no restraint. What I do have is a lightning-quick metabolism acquired through a twist of genetic fate. In fact, twists of genetic fate have a significant influence on who develops not only diabetes but a range of chronic diseases.

And it's not just my genes that offset my behavior. According to the Centers for Disease Control, I earn more than twice as much as most of the million or so New Yorkers who suffer from type II diabetes. While I'm not using that extra money to shop at the pricier health food stores, it's definitely keeping me disease-free in other ways. Research shows that as income goes up, social networks improve and stress levels go down. Both of these correspond to better health. So does education. Studies show that it exerts an even stronger influence on health than income, occupation, or access to health care, in which case I should get a health offset credit for having two master's degrees.

But there are other things working against me, too. A study of more than 10,000 English civil servants found that job hierarchy was strongly correlated with mortality, even after risk factors like smoking, diet, and access to health care were accounted for. And animal studies have shown that beta (low status) rats suffer more severe blockages in their coronary arteries than their alpha (high status) counterparts. So if I get coronary artery disease, my position at the bottom of NEWSWEEK's masthead might be as much to blame as anything else.

Quitting smoking definitely falls into the plus column, but by living in New York City, I still face the same level of risk for lung cancer that I would if I lived with a smoker.