Why Personal Responsibility Won't Fix Health Care

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.

Of course none of this information will stop people from blaming the less healthy among us. When we say that people fall ill because they eat too much, drink too much, work too much, or don't sleep enough we are also saying that by not doing those things we can avoid the same fate. Blaming the individual gives us a sense of control over an uncertain future. It's also easier than contemplating our own mortality.

The obese make an easy target for our judgemental minds, but even cancer patients have not been exempt. Did they smoke? Did they get screened as often as they should have? "We tend to adjust our level of sympathy based on these factors," says Edward Kim, a lung oncologist at M.D. Anderson Cancer Center. "It's too frightening to acknowledge that smoking isn't the only way to get lung cancer." In fact Kim says, 15 percent of lung cancer patients never pick up a cigarette and the vast majority of smokers never develop lung tumors. The same goes for neck and throat cancer. Not too long ago, both were thought to be triggered by heavy smoking and too much alcohol; it turns out they're caused by HPV, a virus that infects 20 million Americans but only turns cancerous in some. And four common cancers (bladder, stomach, large intestine, and rectum) have been statistically linked to the proximity of toxic waste sites. The federal government takes about six years to designate such sites for clean up. They take twice as long in minority communities, which helps explain why most cancers are more prevalent in blacks and Hispanics.

None of this is to say that we should absolve ourselves of all personal responsibility. Those of us who can afford to join a gym, see a doctor and eat healthier foods should do so. And eliminating trans fats, banning smoking in public places, and giving everyone health insurance are worthy first steps towards a healthier country. But human behavior is guided and constrained by a variety of forces, and if we want to wrest our GDP from the clutches of health care, the government will have to look beyond diet, exercise, and health insurance and pay more attention to food policy, environmental protection, and education. To reduce the incidence of cardiovascular disease, how about regulating the salt content in processed foods? It's been nearly three decades since the FDA commissioner called for reductions in processed salt, and regulations have yet to be issued. In that time, salt intake has increased by 55 percent and cardiovascular disease has hit astronomical rates.

To prevent more cancer, try picking up the pace on toxic waste clean up. And while we're at it, why not make obtaining a high school diploma a matter of public health? "We need to assess every government policy and program for its impact on health," says Michael Marmot, commissioner of the WHO report. "Health and health equity should be a marker for government performance." When it is, maybe I'll start eating salad.

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