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“The true front lines in the fight for community health and wellness are far from the sleek conference rooms where many of the campaigns are designed. They are not in insurance company actuarial tables, or at the construction of jogging tracks and health clubs.
“The front lines are in places like Benton Harbor…” (Story continues in Michigan Initiatives.)
Policy change may not be the only route to better health. After all, we are seeing an array of grassroots efforts — change from within — emerging from local organizations, neighborhood groups and citizens in communities around the country. But policies can be enablers or inhibitors of local change.
Let’s look at obesity. A community may come together around reversing the epidemic. They may target access to healthy food as a key determinant. And they may set about addressing the issue through local solutions like community gardens, incentives to bring in more vegetables from regional farms, tighter school nutrition oversight and supplier-partnerships, and a healthy corner store initiative. At some point, even these local efforts may bump up against larger policy structures, and these structures may support or inhibit success.
That’s one of the ways to read Planting the Seeds for Public Health: How the Farm Bill Can Help Farmers to Produce and Distribute Healthy Foods, released last week by Farmers’ Legal Action Group, Inc. The new report shows that federal policies impede farmers’ ability to make fruits and vegetables more widely available and affordable.
A Policy Highlight document cites:
Today, many of our communities are unhealthy—dominated by fast food, with few full-service grocery stores that stock affordable healthy foods. In addition, many students receive school meals that do not meet federal dietary guidelines. Almost a third of our nation’s young people are overweight or obese, and youth from low-income households, Blacks, Latinos, American Indians and those living in the southern part of the United States tend to be disproportionately affected. Success in reducing and preventing the childhood obesity epidemic will depend in part on the degree of success farmers experience in producing and marketing healthy crops, such as fruits and vegetables.
Planting the Seeds for Public Health: How the Farm Bill Can Help Farmers to Produce and Distribute Healthy Food… highlights the barriers the agriculture community faces in ensuring that our nation’s children have ready access to healthy foods.
The full report is available here.
“The influence of social relationships on the risk of death are comparable with well-established risk factors for mortality such as smoking and alcohol consumption and exceed the influence of other risk factors such as physical inactivity and obesity,” according to a newly published study in PLoS Medicine.
See related coverage in Time and Stanford Medicine’s Scope. Also see previous blog posts, The Drug Is Us and The Social Contagion of Health.
In the August issue of Health Affairs, leaders of the Robert Wood Johnson Foundation Commission to Build a Healthier America show how improvements in education, economic opportunity, and quality of neighborhoods can lead to better health for all Americans. This is particularly important given the alarming rise in chronic conditions and costs — and the significant potential return on improving our nation’s health:
Download the Health Affairs article here.
The August CDC Vital Signs reports that the number of states with an obesity prevalence of 30 percent or more has tripled in two years. People who are obese had medical costs that were $1,429 higher than those of normal weight, with a total of $147 billion in medical costs associated with obesity in 2008 dollars.
“Obesity is a complex problem that requires both personal and community action,” said CDC’s William Dietz, M.D., Ph.D. “People in all communities should be able to make healthy choices, but in order to make those choices there must be healthy choices to make. We need to change our communities into places where healthy eating and active living are the easiest path.”
The report and U.S. obesity map are available here.
Tomorrow, July 27, is the last day to register for the Robert Wood Johnson Foundation and Grantmakers in Health 90-minute webinar: “A New Way to Talk About the Social Determinants of Health.”
Scheduled for Thursday, July 29, 2010 at 3:00 p.m. (EST), this webinar will summarize research and share the most effective way to reach the widest audiences:
Register here.
Before getting into why I think we should be leery of commonplace notions, I should define what I mean by the term. First of all, merely suggesting that there’s something wrong with commonplace notions might itself sound wrong. After all, commonplace notions are commonly understood to be the agreed understandings of the world that keep the world on track. But when we see that in certain respects the world is not really on a track anyone would call a good track, we might want to look at the commonplace notions keeping it there as a reason for this. One of the ways I define commonplace notions is that they lead us astray and compel us into actions that betray our best interests. Both to make this argument and to further define the term I offer the following examples.
This morning for reasons that aren’t important I began thinking about the commonplace notion that fifty-percent of marriages end in divorce (well, maybe they are important: I listened to a radio show discussing the institution of marriage, in light of the Gores’ recent announcement that they are separating; a decision, I was told by the show’s host, that’s sparked a “national conversation” on marriage).
For as long as I can remember people have talked about a fifty-percent divorce rate. We have been told and told each other and told ourselves that one out of every two marriages ends in divorce. The effect of this notion is profound. It creates a backdrop against which we think about marriage. It turns marriage into a gamble — a crapshoot, or a coin toss — which in turn can make it seem as if a decision to end a marriage is all but fated. It corrupts the equally fraught notion of commitment.
The commonness of the fifty-percent notion is built upon a foundation of slipshod thinking. It turns out the fifty-percent statistic is an aggregate of all marriages, i.e., marriages in all age groups, in all economic conditions, in every social stratum, etc. The function of a commonplace notion is to personalize a general observation. For example, a person of any age, any economic circumstance, any background can come to believe that his or her marriage has only a fifty-percent chance of lasting a lifetime. That’s what the commonplace notion tells us. The data, however, show something else. For people from certain specific age groups the chances of having a marriage that lasts a lifetime are much better than fifty percent. This fact is much less well known than the commonplace notion that fifty-percent of marriages end in divorce.
Commonplace notions seduce us into a faulty understanding of some part of the world and then to act in ways that disregard less well-known facts about that part of the world. And it is a seduction, speaking seductively to a pervading resistance to the subtler enticements of rigorous thinking. This phenomenon has direct application to work being done by public health officials, community agencies, government, academia and business to improve health by championing wellness and pursuing a social determinants approach to health. Again, an example might be helpful.
For several years the trend in health insurance has been to ask subscribers to assume more responsibility for their health. In the euphemistic vernacular of the industry this is called employee engagement. (It probably shouldn’t go unsaid that they’re also being asked to assume more of the cost for treatment when their health fails.) Asking this of subscribers runs afoul of the commonplace notion of health, which exclusively associates health with medical treatment, medical treatment subscribers don’t know how to value. Accordingly even for those with unmanaged chronic conditions health is a background concern; it’s a given until such time the condition flares up and they’re forced to seek medical treatment. Asking people to participate in wellness and prevention programs under the auspices of a health insurance plan is an affront to the commonplace notion of health; read, an affront to the way people have come to take a place in the world.
I wonder if the challenges and failures of employee engagement aren’t somehow evidence of this running-afoul of the commonplace notion of health-as-medical-treatment. It might be that for the ninety percent of employees who aren’t engaged (don’t take advantage of the benefits provided to them) it just doesn’t fit the norm to think of health in terms of wellness and prevention. Which means they’re not intrinsically motivated to take advantage of their benefits. Add to that the implicit admonition that attends messaging telling them to change the way they live, and it’s a wonder an employer can claim even ten percent compliance with the new dictates.
This is where a community/social/ecological approach can potentially change the game. If a community/social/ecological approach can be notioned as vitality (to pick one word not thoroughly usurped by the health-as-medical treatment notion), and if it can be partitioned from health insurance benefits, there is the possibility of people changing their behaviors, not because they’ve been told that what they’ve been thinking all this time is wrong but because they’ve been given the space and permission to think anew about their health.
A federal working group report released last week highlights 11 categories of diseases and other health consequences — from asthma and cancer to neurological and stress-related disorders — linked to climate change. “This white paper articulates, in a concrete way, that human beings are vulnerable in many ways to the health effects of climate change,” said Linda Birnbaum, Ph.D., director of the National Institute of Environmental Health Sciences (NIEHS) and the National Toxicology Program, whose institute led the interagency effort.
A workaround, according to Wikipedia, “is a bypass of a recognized problem in a system…a temporary fix that implies that a genuine solution to the problem is needed. Typically they are considered brittle in that they will not respond well to further pressure from a system beyond the original design. In implementing a workaround it is important to flag the change so as to later implement a proper solution.”
Of course, “later” is always “later.” And “implementing a proper solution” means that we will need to acknowledge the underlying causes of the problem we had previously decided to “bypass.” And when we do decide that “later” is now (perhaps when “further pressure” from the “system” becomes too much for our “brittle” workarounds to bear) – and we are finally willing to address the “recognized problem” with a “genuine solution” — will we undo all these “temporary” changes we so diligently remembered to “flag”?
Phew! Makes me wonder why we bother with workarounds in the first place…
And yet, even as First Lady Michelle Obama hits the airways to promote Let’s Move, the national campaign “to solve the epidemic of childhood obesity within a generation,” we are seeing a range of very inspired, apparently well intended, though too often superficial, fixes. It all seems a bit nip-here, tuck-there when the “genuine solution” we need is nothing short of a complete transformation.
But let’s give credit where credit is due. Quite a few of these fixes are, as the Wikipedia definition goes, “as creative as true solutions.”
For example, just last week we read about an innovative effort in Baltimore that uses libraries as “virtual supermarkets” to work around severe nutrition gaps in the city’s food deserts. We heard snack and soda companies vow to alter their ingredients and distribution practices to work around the prospect of a more drastic step: abolishing or taxing their products. And we learned of a new bill that dramatically reduces the money requested for school food reform to work around the lack of support for an earlier proposal.
One could argue that this is good, tangible progress. To be sure, each of these actions will produce a result. And perhaps quick fixes are a way to get us moving, which seems to be the spirit of the Let’s Move campaign. One could also argue that, for the most part, we are tiptoeing around the edges of a fundamentally broken system, which we avoid like the elephant in room, as we go about the business of gathering low-hanging fruit.
A step further would be to acknowledge these and similar fixes as provisional, and to commit to measuring their impact as well as their shortcomings, as we continue with equal passion the ongoing work of uncovering the roots of the epidemic. In this work, we begin with questions rather than fixes. We ask, for instance, why is it that food deserts exist in the first place?
We might even begin to unravel that most gnarly of hairballs at the center of the obesity epidemic: How is it that America became, as Newsweek’s Claudia Kalb puts it, “the world’s preeminent fat-making machine”?
We got here through multiple innovations, many of them meant to improve, not corrupt, our lifestyles. Fast food is a quick fix for hungry working families. Cars and buses get kids to school faster than sidewalks. We have grown used to a world order of speed and convenience…
“The National School Lunch Program, signed into law in 1946 by President Harry Truman, was designed to feed hungry children who needed extra calories… With a focus on standards of learning propelled by the reading- and math-focused No Child Left Behind Act, many schools cannot afford, financially or academically, to offer physical education… Our suburban designs, influenced by age-old zoning laws, also work against us… And then there’s rampant marketing. Food and drink advertising to children… (And) government subsidies on abundant commodities like corn and soy. High-fructose corn syrup, synthesized from corn, is a main ingredient in a multitude of sweetened drinks and snacks.”
In short, she concludes, “An entire cultural shift is required.”
So, when it comes to childhood obesity, will a new round of workarounds work? Will they see us through until we get to a genuine solution? Will we question after the root causes? Or will we keep adding workarounds to our workarounds, with the illusion of progress, until our passion turns to complacency, or resignation, or distraction — or whatever it was that consumed us when we first saw the trends (5, 10, 20 years ago?) and decided that a “proper solution” just wasn’t palatable?
As the First Lady writes in her recent Newsweek article, “For years, we’ve known about the epidemic of childhood obesity in America.” The good news, she notes, is “that we can decide to solve this problem.”
A genuine solution will not just tweak the existing structures and make up for the inadequacies. Deciding to “solve this problem” requires a more fundamental examination of, in Kalb’s words, how “we got here.” Just how is it that we have created a system perfectly engineered to produce the results we’ve got (nearly one-third of American children and adolescents are overweight or obese)?
More precisely, we need to examine who we were being when we created the current system. And who we must be to transform the system (and ourselves) to produce the results we really want.
Additional coverage of the story unfolding in Benton Harbor, Michigan: “Businesses join to educate community on health,” Employee Benefit News.
