Healthful Behaviors: Why do people adopt them? Or not?

While I am not a psychologist or psychiatrist, I am both a family physician and a person. As such, I have observed human behavior for a long time. I have noted some psychological behaviors seem to be very common in the people that I have met both personally and professionally.  I won’t say that they are “human nature”, since this phrase almost always refers to something that the speaker believes in or finds dominant in his/her environment, and is usually very culturally bound. However, they are common. One of these is the tendency to deny the magnitude of risk inherent in the risky things we do (or the risks we take because of things we don’t do). At the same time, we magnify the degree of risk inherent in the things we pride ourselves on not doing (or doing, when we see doing them as if beneficial, and not doing them as risky). As a corollary, we are likely to criticize those who adopt the risky behaviors that we do not, or do not adopt the beneficial behaviors that we do. That is, judging others is easy.

Perhaps because many of these potential risks are to our health and safety, these attitudes are common in health care and public health workers. Health professionals who do not smoke, and have never smoked, often severely condemn those who do. But alcohol? A little wine is good for you, right? Maybe, but it depends on who you are. If you have a tendency towards alcoholism, or are pregnant, or are going to drive, it is not good for you. Or for others. Public health workers can strongly advocate for wearing bicycle and motorcycle helmets, and using infant car seats, but it is just possible that once or twice they were late for something and drove too fast or too carelessly. And hopefully didn’t have an accident, but could have, and certainly increased their risk for it. From a risk/benefit point of view (fire trucks and ambulances and police aside), being late for work is NEVER a reason to drive faster or more carelessly; in fact, because there is a natural temptation to do so, conscious governance of that temptation is the beneficial behavior.

The utility of adopting a healthful, or not adopting an unhealthful, behavior is complex. It depends on the likelihood of something bad happening, how bad that thing is, and how many people it affects. So eating unhealthful food and not exercising is bad, but mainly for the person (and their immediate family) if they get sick or die. Smoking in public places, and even more, driving less than carefully or under the influence of alcohol or drugs potentially affects more people. Not immunizing your children because it allows you prevent a common but unpleasant effect (getting a lot of shots) and possibly a bad but extraordinarily rare long-term effect (whether real, like Guillain-Barre from swine flu shots or not, like autism[1] must be balanced against both the risk of their acquiring the disease and its sequelae, as well as the impact on the overall population that results if lots of children, not just yours, are unimmunized.

Not long ago I saw a patient in her early 30s who was pretty obsessed with getting breast cancer. She had no particular risk factors (no first-degree female relatives with it), but had previously talked a physician into ordering a mammogram when she was just 28 (it was normal), and wanted another one. We discussed the risk, but she was pretty fixated on breast cancer. We also talked about other risks, of much more concern to me than to her: smoking 2 packs of cigarettes per day, having 3 different sexual partners and rarely using condoms, and having untreated hypertension. I suggested, strongly but I hope appropriately, that all of these were much greater risks to her health than was breast cancer. I don’t know that I got through.

I imagine that it is pretty easy for health professionals to agree with me about the relative risks for this woman. Why she was so concerned about breast cancer rather than her real risks is another question. Some obsessive neurosis? Excessive effectiveness of breast cancer awareness advertising? I’d suggest that in large part it is about personal responsibility, about whether she would have to take action to prevent a bad outcome. If she were really worried about the risk from blood pressure, from smoking, from unprotected sex with multiple partners (and she should be), she would have to do something, take some action to change her life, to take medicine, to give up an addiction. This would be hard. On the other hand, since there are no clear behaviors she would need to change to avoid breast cancer, this is a safer – that is, less challenging – thing to be concerned about, to be fixated on.

Are the rest of us so different? Even those of us who have almost no dangerous or risky habits or behaviors (are there such? If we apparently have none, there is a fair chance that we might be suffering from obsessive-compulsive disorder, also a potential risk!) Besides, some of us may always take care to wash our hands when using the restroom (and even use our elbows to turn off the water, as I saw a very young man do in a public place the other day), but take the risk of riding our bicycles on public thoroughfares. Or we may practice what we believe to be healthful eating, and may regularly ingest herbs and give our children vitamins that there is little or no data to support doing, but not give them immunizations.

Reducing health risk is also impacted by societal memory, or the lack thereof. This has been examined in the case of abortion rights, where younger women who have grown up during a period when abortion was legal (if increasingly unavailable, largely resulting from the campaign of terror from violent anti-abortion forces) do not see the urgency of fighting to continue it. It also often true in the case of HIV/AIDS, where young people who did not grow up seeing all their friends die of the disease before effective treatment was available may find themselves adopting the same high-risk behaviors. Or for those who never saw the devastation of epidemics of pertussis or diphtheria, or of measles, or of awful outcomes from Hemophilus influenza infections, to not see immunizing their children as critically important.

In addition, when we as individuals have good outcomes (or don’t have bad ones) we may tend to think it is deserved rather than attributing it to good fortune. We haven’t had car accidents because we are good drivers, not because we are lucky. We think we are healthy because we bike to work, or “eat right”, not because we are young and in a low-risk group. When we are older, we may believe that we are less ill than our friends because we do healthful things like yoga or take certain herbs, not because we lucked out in not getting cancer (or being born into a family with resources who could feed us well and educate us and provide us with other advantages) See also Social Determinants, Personal Responsibility, and Health System Outcomes, Sept 10, 2010).

I am not going to say “let s/he who is without sin cast the first stone”. I would, rather, ask all of us to recognize that an honest appraisal of our own risk behaviors is a first step to understanding those of others, and to helping them, and helping our society, achieve greater health.

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[1] Data on vaccines presented at the recent American Academy of Family Physicians (AAFP) meeting suggest the chance of an adverse vaccine outcome is approximately equal to the chance of winning the lottery, and that of dying from a vaccine about equal to spontaneously having quadruplets.

Social Determinants, Personal Responsibility, and Health System Outcomes

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Whole Foods, Inc., CEO John Mackey has been both an outspoken critic of the Obama administration's health reform plan and an advocate for “personal accountability” suggesting that people’s health behaviors – including such things as smoking, poor diet, obesity, and lack of exercise -- account for much of their health risk, and thus people should be held responsible for the poor choices that they make, receiving fewer health benefits if they have not taken the steps to maintain their own health. He has recently made this argument in an op-ed piece in the Wall St. Journal, “The Whole Foods alternative to Obamacare” (August 11, 2010). Subtitled “Eight things we can do to improve health care without adding to the deficit”, Mackey runs through a list of proposals that feature inequity, maintaining and increasing the health and wealth of those who already have the most of it; that would create enormous increases in insurance company profit, would not meet the health needs of those who have needs, and would end up costing a fortune. The “controls” are all on services that would benefit people, the “freedom” is all for corporations to continue to have unfettered access to excessive profit.

“All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments,” he writes. Of course, his definition of “socialized” includes the health systems of every single developed country in the world outside the US, whether they have a National Health Service (e.g., UK), single-payer insurance (e.g., Canada) or a mixed system that includes private insurers that are regulated (e.g., Switzerland, Germany). What is unsaid by Mackey is that the system he proposes (much like the current one in the US) does not eliminate lines for everyone but rations by wealth and insurance status. CEOs like him do not have to wait in lines, but the further down the socioeconomic ladder you are, the longer the line becomes, until, at the end, unlike in those other countries, there are tens of millions of people who can’t get on the line at all. Unsurprisingly, these proposals are likely to resonate with and please the readers of the Wall St. Journal’s editorial pages. The US health system is not only incredibly expensive (not because it covers everyone, which it doesn’t, but because of the huge profits taken out of the system by Mackey’s fellow CEOs) and unfair, but it performs poorly on virtually all dimensions (see the Commonwealth Fund’s 2010 report, “Mirror, Mirror on the Wall”, with results summarized in the attached figure).

More insidiously, however, some of these arguments can appeal to many others, who see sense in expecting people to take “responsibility” for their health and act in healthful ways: “Unfortunately many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.” Eat nutritious food, exercise, don’t smoke or take illegal drugs or drink to excess, etc. This is good advice, and all of us should try to take it. I’m sure that it is advice that many of the employees of Whole Foods – the ones who are young and healthy – appreciate, because it validates what they do, and see – the “outcome” is that they are young and healthy. It is possible that there are other Whole Foods employees, not young and healthy but older and/or with chronic disease – who many not find his advice, or the company’s health plan, to be of such great value. His essay may be a call to action for those who, given some combination of youth, genetic luck, good health, and socioeconomic opportunity, are still not doing all they can.

But health behaviors – and the health care system – are not the only determinants of health. Indeed, the Determinants of Health model from Healthy People 2010 (see figure) make clear that there are m any factors that impact health, most of which are ignored by Mackey and his ilk. They are also not all going to be addressed by health system reform, whether that in the current “Obama” plan or even in a more extensive change, advocated by people like me and the Physicians for a National Health Program to be more like the other, much higher performing systems in other countries. That system change is necessary, but not, in itself, sufficient. The environment, both physical and socio-economic, have tremendous impact. In addition, issues not specifically on this model, such as the impact of race (racism, not perhaps overt but in terms of the impact of “perception of race” on those of color). These are the Social Determinants of Health, and have been written about extensively, in a literature that is either unknown to or rejected by Mackey and his friends. Perhaps the clearest exposition of the Social Determinants is by Camara Phyllis Jones, MD, MPH, PhD, of the Centers for Disease Control and Prevention (CDC), who has written extensively on this topic. However, she has also developed a cartoon depicting how the social determinants of health intersect with the health care system as well as how the different levels of the health care system (primary, secondary, tertiary prevention, and treatment) interact with each other. Her slide show, “Social Determinants of Health and Equity, the Impacts of Racism on Health” is available on line and contains these cartoons. They demonstrate, through the use of a cliff analogy, the role of these different factors. Although very useful for teaching children, their clarity is also of great value for teaching health professionals. And they might even be understood by CEOs.

With Dr. Jones’ permission, Neal Palafox, MD, of the University of Hawaii, produced slides based on her model, one of which is reproduced here. It represents health risk as a cliff. If someone falls off, we can provide medical care (the ambulance); however this is variably available for people (access to care). If we can identify diseases and treat them before they require expensive care, this is secondary prevention (the net also represents “safety net” health services). Better yet, we can provide primary prevention – keep people from falling off the cliff (the fence). Some of this is achieved through the individual behavior changes like those advocated by Mackey. The social determinants, however, which he ignores, are represented by the distance that people are from the edge of the cliff; some folks are at greater risk. As Dr. Jones also develops in her slides, many of those same people are those who have less protection by the fence, or the net, or for whom, when they do get sick (fall off the cliff) the ambulance is not there, or even “going in the wrong direction”.

Most of the discussion of these issues are among those of us who are relatively privileged. We may not be wealthy CEOs like John Mackey, but we are educated, literate, and consumers of ideas. Most of us are at least middle-class; even those who may say “no, I don’t have money” are usually in that status temporarily (e.g., from being students), but have the values and self-efficacy that comes from our class, socioeconomic, and educational background. This group certainly includes all the politicians, pundits, academics and successful businesspeople – and medical students. It may be hard to believe, but the vast majority of people are not in that group. Check out income demographics: according to the US census, in 2000 only 12.29% of households – not individuals – had incomes over $100,000 a year, and only 2.37% over $200,000; 2008 estimates indicate household income >$100,000 is the top quintile, and the top 5% is >$180,000.

We absolutely need health reform, real reform, that will begin to move us in the direction of the high-performing health systems in other countries. We also need to encourage healthful behaviors. However, rather than penalizing others whose circumstances – genetic, socioeconomic, social, racial, physical – make that more difficult, we need to develop programs, that require, as Dr. Jones notes, “…collaboration with multiple sectors outside of health, including education, housing, labor, justice, transportation, agriculture and environment.”

And we need to get started.
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