Today is the first day of a 2-week, intensive course – Problem Solving in Public Health – that I teach twice yearly at Hopkins. It’s a great course. I co-teach it with Bob Lawrence, a pioneer of public health, preventive medicine, and human rights. We teach a systematic method for addressing public health problems. More on that another time.
I bring this up to share a quote we frequently use in our lectures:
Should medicine ever fulfill its great ends, it must enter into the larger political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life-cycle and remove them. Should this ever come to pass, Medicine, what ever it may then be, will become the common good of all. – Rudolf Virchow (1821-1902)
Rudolf Virchow, a famous physician whose name is well-known to any 3rd year med student vis-a-vis “Virchow’s triad” (which describes three categories of common factors that can lead to deadly blood clots), expertly states here a core message of public health: our behaviors and our health outcomes depend on much more than our individual choices. The physical environment, social environment, and other factors that surround us largely shape who we are and what we do.
Here’s an example: As a group, white Asian women in Bergen County, NJ, a well-to-do suburb of New York City, live longer than anyone else in the U.S. Their average life expectancy is about 91 years! In contrast, many groups of African-American men in poor inner cities live just 56 years. That’s 35 years difference. Amazing.
What differs between these two groups? What barriers “obstruct the normal completion of the life-cycle” in these African-Americans and other sub-populations with significantly higher rates of disease and lower life expectancy? Public health, economic theory, and plain old common sense tell us that if you traded the circumstances in which they live with those in which Bergen County’s Asians live, the life expectancy outcomes would follow suit. Modern economic theory, in particular, describes the situation well: economic theory says we’re all equal; life circumstances make the difference.
Poverty, socioeconomic status, education, surroundings. These, among others, largely defines life’s path for many. This doesn’t argue against free will; any individual can, and some do, buck the odds. But our surroundings are such a powerful determinant of our actions and health outcomes that, on the level of the population as a whole, very, very few do.
We’ve got to remove the barriers that obstruct the normal lifespan.
By the way, this very much applies to obesity. As the food and physical environments (as well as the workplace, home, and other contexts that surround us) have changed since the 1970’s and 80’s (and, actually, since the turn of the industrial revolution – but that’s a story for another day), our weights, rates of obesity, and chronic disease have grown significantly. 70% of Americans are overweight or clinically obese; of those in the normal range, LOTS are gaining weight at a pace that will put them in the overweight or obese range soon enough, and many others are leading as unhealthy lives as anyone else but are largely “resistant” to significant weight gain (yes, I hate those folks, too). The fact is, there is exceedingly few people in America who are able to maintain a healthy weight and a healthy life in our environment – even as our society so values thinness (and extreme thinness). Doesn’t seem possible to me that all this weight gain affecting nearly all Americans could possibly be due “low willpower.” If anything, we – nearly everyone – don’t have enough willpower to counteract our incredibly obesogenic (obesity-causing) surroundings. While aiming to eat healthily and exercise is, of course, important, simply motivating ourselves to diet and exercise won’t solve this problem – after all, we’ve been doing that for a long time, and the numbers just keep increasing. Just as Virchow argued that medicine cannot achieve it’s ultimate ends – to improve health and life among the population – simply by treating one patient at a time, to continue telling people to just “eat less and exercise more” or to have more “self-control” is useless. We must remove the barriers that obstruct the normal lifespan.