If we want healthier communities, we must stop thinking of health only as a matter of personal responsibility and lifestyle choices, and dive deeper to the greater social determinants.
Jared Knoll: Welcome to Upstream Radio, where we dive deep into all the social and economic determinants of health — the source causes of how we live and when we die. I'm Jared Knoll. Today we're looking at behaviour, at what we think of as the lifestyle choices that keep us in good health.
(Sound Bite; Dennis Raphael): Sociologist Sarah Nettleton termed it the holy trinity of risk: physical activity, diet and tobacco use.
JK: That probably sounds like a pretty familiar set of health risks, from visits to the doctor, from articles you've read and from pretty much everything you've ever heard and seen in popular culture. There's just one problem.
(SB; DR): There's a vast amount of evidence that indicates that all of the behaviours that we're so concerned about only account for, at best, 10% to 15% of the variation in health outcomes.
JK: Now, that doesn't mean we should stop paying attention to our diet, activity levels, and avoid unhealthy behaviours like smoking. Keep doing those, those are good things. They always have been. What it means is that those of us who adhere to those sorts of behaviours, or don't, tend to do so because of the social and economic advantages we happen to have, or don't. Let's take exercise, for example.
Brendan Groat: It's easiest for people to exercise if it fits into their life. People of higher socioeconomic status, they might consider exercising something you do after work, and something they do in their time when they're not working.
"With all this attention to the so-called lifestyle approach, all it really does is actually increase health inequalities, because the people that are in the best condition to actually make these changes in their lives are already the ones that are going to live longer anyway."
So I guess in that context, you have to be able to have a job that provides you enough time to exercise, and to have enough funds to be able to put towards exercising, whether that's in a gym or wherever you like to exercise. But more importantly, for lower socioeconomic status individuals, who oftentimes have poorer health, they might be working multiple jobs and might not have time to exercise, and certainly not funding to put towards going to a gym or something like that. But their exercise maybe could be fit in transportation to and from work, whether that's walking or biking. But of course, for those you need appropriate clothing and a bicycle that is functioning.
JK: So healthy behaviors like maintaining an active lifestyle and eating a nutritious diet are extremely important for our health, but it's not enough to just tell people to be healthy. We have to change the social, economic and political barriers that get in the way. That's what the evidence is telling us. We can't afford to remain in this trinity trap, stuck in the conventional wisdom of past eras, doing and saying things like:
Sound Bite: I'm Justin Trudeau. Men's Health Week starts on June 13th, and I'm joining their Don't Change Much campaign, which reminds us you can make small changes in your life and enjoy big benefits to your health. You don't have to take up yoga or lace up the boxing gloves to make a difference. Drink more water, eat healthier food. Take the stairs instead of the elevator. Get off the bus one stop earlier.
JK: One of our most important pieces of literature in Canada on the broader social and economic determinants of health, is called The Canadian Facts. I asked its author, Dr. Dennis Raphael, how we got to where we are now.
JK: When we talk about lifestyle drift, what do you see as the biggest problem with understanding how behavior affects health in Canada?
DR: Historically, health has been seen as healthcare, or promoting health, or preventing disease. Over time there's always been a tension between what we might call the broader environmental approach, and the individualized behavioral approach.
For example, during the social justice movement of the late 1800's in the United States, there was a recognition that many of the causes of illness and disease were not rooted in individual pathology, but in the conditions under which people were living in society. And even earlier, in the 1840's and 1850's, Friedrich Engels wrote about the condition of the working class in England, and Rudolf Virchow in Germany wrote about the politics of disease and illness, where he said the lack of democracy and equity was responsible for disease.
"Rather than raise the issues of income and democracy and political control and power, they end up ignoring all of those and telling and implying that the causes of disease and illness are people's adverse behaviours."
In Canada there's always been this tension, but even since the 1970's with the Lalonde Report, and then 1980's with the Epp Report, which the world sees as the great example of Canada being a leader in health promotion and raising broader issues. This concern with broader issues has always been secondary to a belief that health can best be promoted by getting people to behave the way we might like them to behave.
Sociologist Sarah Nettleton terms it the holy trinity of risk: physical activity, diet and tobacco use. The problem with this is that evidence has always been available that not only do people's environmental circumstances, their living and working conditions, not only do these conditions have a much more important effect upon health outcomes, but these conditions also shape the behaviours that so many people are concerned about.
There's a vast amount of evidence that indicates that all of the behaviours that we're so concerned about only account for, at best, 10% to 15% of the variation in health outcomes.
JK: So if the data is telling that these behaviours, smoking, diet, exercise, have a relatively minor impact on health outcomes, and if these behaviours themselves are largely determined by things like income and education, what should health professionals like doctors be doing differently?
DR: What they should be doing is recognizing, as Randolph Virchow pointed out, that medicine is actually a political activity, and that certainly, all things considered, you don't want people, if they have some control, to smoke. We much prefer that people have a balanced diet, and certainly all things considered, we'd want people to be more active than less active, but these factors themselves play a rather small role in health outcomes. The danger to all of this is that what it does is diverts attention from these far more important issues of living and working conditions. Also, the evidence that these so-called lifestyle approaches will actually improve the health of the most vulnerable is completely lacking.
What actually happens, with all this attention to the so-called lifestyle approach, all it really does is actually increase health inequalities, because the people that are in the best condition to actually make these changes in their lives are already the ones that are going to live longer anyway, and it's an insidious process whereby even when governmental and other agencies recognize the broader determinants of health, what they do is in their practical recommendations they drift, such that the term "lifestyle drift" has come to refer to the tendency of all of these public health, health agencies and governmental agencies, to rather than raise the issues of income and democracy and political control and power, they end up ignoring all of those and telling and implying that the causes of disease and illness are people's adverse behaviours.
"For every one article that is about the broader determinants of health, there's 150 articles about obesity or lifestyle."
JK: How do you think we got here? How do you think we got to the point where we are blaming personal responsibility as the determiner of our health?
DR: Well, Canada, political scientists talk about different forms of the welfare state, where the so-called liberal welfare state is the Anglo-Saxon approach to societal organization, where the marketplace and the so-called free enterprise sector is the dominant institution. The primary ideology associated with this historically is that of individual responsibility, individual control, the belief that all individuals have the ability to make decisions that will not only shape their economic future, but will shape their personal future, and this lends itself very much to the so-called lifestyle approach, biomedical approach, where the broader issues are ignored and the focus is turned to the individual. This serves interests, some interests very well. It's in the interests of those that have power and influence to attribute disease and illness to individual failings, rather than the business and other practices that lead to gross inequalities in living and working conditions.
JK: You've been tackling this since the beginning of your career in the social determinants, when you beheld this thing, the American dream or the Canadian dream if you like, where it's up to the individual to achieve their own well being and success, and then in reality doesn't actually match up to that. And since then, since the beginning, and since you wrote The Canadian Facts, and since then we've seen this slowly growing movement in academia, and then more recently, a slowly growing social movement, more and more people are coming to understand that the most important things are the social things, are access to food and housing and childcare, and a decent income and stuff like that, yet we still see this resistance when it comes to behavioural choices, when it comes to smoking and eating nutritiously and getting enough exercise. Do you think, is there something missing? Is there something special that keeps people more resistant from accepting the social and economic causes of these?
DR: There are always conflicting trends and tendencies in society. For example, the typical health scientist, a typical epidemiologist, a typical health reporter, is trained in the biomedical approach, is trained in the so-called lifestyle approach, and no matter where you are, whether you're in Norway or Holland or in Canada, if you get 150 epidemiologists who have that approach together, they're going to talk about lifestyle, they're gonna talk about biomedical. The difference is, is that in nations such as Germany or Norway or Belgium, the powers that be, whether they're the business sector or the governmental sector, recognize that that's what they're gonna say, but they also have access to broader concepts of human health and the role of society, so they act as a counterweight.
If the broader context of a society is oriented towards individuals, is oriented towards denying the role of broader structures, then the parts of the health sector that are traditionally biomedical and/or behavioural approach continue to dominate, because there's no counter force against them. For every one article that is about the broader determinants of health, there's 150 articles about obesity or lifestyle.
JK: So in your experience, like if you show people that, take smoking, for example, people in low income brackets are overwhelmingly more likely to smoke, and the better education you have the less likely you are to smoke?
DR: That's right. And the more precarious your work is the more likely you are to smoke...
JK: ...the more stress in your life and the fewer opportunities to relieve stress through expensive activities like warm vacations...
"Do those people just need to be told to not smoke? Just need to be told to breathe more? That's not what the evidence is telling us."
DR: ...or not being, having no food as an indigenous community. But what they hear, what they take away is, "oh, we have to help people to stop smoking." It doesn't even get processed, even when people like ourselves have these nuanced models that say 80% of the variance is due to living conditions, and these living conditions also shape the remaining 20%, which is tobacco use, the only thing people hear is tobacco use.
JK: We see the same thing happen with diet and exercise, with dozens and dozens of studies showing that socioeconomic status is correlated with obesity rates across the board, and the greater inequality of wealth in a society, the greater inequality of health too. But instead of real solutions, we get, "Walk more, breathe more, sleep more." We get, "Don't change much." We get a focus on super foods and the newest fad diet or home gym gimmick, and we get blame on the individual. Patty Thille is a post-doctoral fellow with the Bloorview Research Institute in Toronto. I asked her why this is and what it costs us.
Patty Thille: There's this belief that shame is going to create change, that shame is a good motivator. The thing about shame is that it doesn't tend to produce those effects. It can produce loathing, self-loathing. It also damages relationships. If you're essentially saying, "Listen, I love you but you are doing these things that are really hazardous to your health." Would you say that to someone who has an eating disorder? Would you that as a loving, caring thing to do, a supportive thing to do? Would you say that to someone who has depression? Would you say that to someone who has red hair, and so their cancer risk is higher? "I really love you, but that red hair," you know, like when you shame them for having red hair. Because the fundamental part about shaming people based on their larger and visibly, like visible fat on their bodies, is that you are assuming somehow that that's changeable.
And again, the research isn't that — there are population changes. There is something changing, and I don't mean to deny that. But the idea that this is just all under individual control. When you think of the vast number of things that have changed over the last 50 years in this society, you start to get into a bit of a hole here. Like you're not — it communicates, when you use shame to try and motivate somebody into changing their behaviour, it generally communicates that you have no idea really what they've been living with, and probably how many times they've already tried to lose weight.
JK: What do you think that we should try to do as advocates, as activists, as politicians, as health professionals, if people care about the health of their communities, what would be a better way than just getting so hung up on behaviour like diet and exercise?
"We know that it's those who are in lower-income brackets are much more likely to be obese, and they're more likely to smoke as well."
PT: In general, I would say we're talking about fostering the conditions in which people thrive. Those are many and they come down to things like housing and transportation systems, how easy is it to meet your basic needs and get around the place? How much are you dealing with on a daily basis? How much time does that eat up? Where are the opportunities to do things that might be really personally valuable and health enhancing if we're talking about supporting healthy behaviours.
But beyond that, I think we really have to talk about moving away from the idea that shaming people for a bodily characteristic is going to produce better health for people. Fundamentally that's the shift that I wanna see, that there are ways to support people and support them in living meaningful lives and that don't have to work through shame, because shame has both very pernicious, awful effects on people's lives when it's sustained and so frequent. But it's also that it takes us, it detracts our attention from better solutions. We have to think better about what we're talking about when we're talking about health, and this is using the example of fatness and fat bodies as becoming a really active target of political attention. But fundamentally we have done a lot of downloading of responsibility onto people when we know that there's so much around them that can make life so much better.
JK: So, what can the health practitioners of the future do to shift that paradigm? Well, first they have to understand where to shift it to. A couple of med students named Giuliana Guarna and Elizabeth Lee recently took it upon themselves to do just that. Some of the things they discovered? Canadian smokers in the lowest income level are twice the number of the those in the highest. Smoking rates among those with a high school equivalency diploma is about three times higher than the national average. Stress is a huge factor, especially among women. And for indigenous peoples affected by unique stressors like past and continuing processes of colonialism and inter-generational trauma? The smoking rate is well over double. Do those people just need to be told to not smoke? Just need to be told to breathe more? That's not what the evidence is telling us. I asked Elizabeth how these facts will inform her practice as a future doctor.
Elizabeth Lee: For me as a future physician, what the research has told me was that when a patient comes in and they are smoking or want to quit smoking, I need to ask about various different things that got them to smoke and are keeping them smoking, keeping them from quitting smoking so that I can actually give help that will be more helpful in the long term.
JK: This is the silver lining and the source of a whole lot of optimism. Thousands of Canadian medical students are already walking a more informed path right now in schools and residencies all over the country. But you may be wondering with all of this, is any of this really the responsibility of a doctor or a health professional to affect policy, to change the world? [I asked Vivian Tan of the Ontario Medical Students Association and one of the contributors to Upstream Medicine, the new book we put out just this year. She's a final year medical student at McMaster University and about to begin her practice as a newly minted doctor.]
Vivian Tam: I had a patient who came in and their child was suffering from asthma. It was starting to get really bad and her young son was starting to wake up at night and to throw up because his asthma was so poorly controlled. We talked about strategies to prevent that and we talked about increasing his puffer use. At the end of the visit, it came out that this young mother asked me, "so would it be okay for you to write a letter that I could bring to my landlord to talk about the mold in our house that hasn't been addressed?" And so really when we listen to our patients, I think they're telling us that they need us to do more and to take action on the root causes of their issues. For this young woman, it wasn't just that her son had asthma, but it was also because she was living with mold in her house. And upstream of that there's the issue of poverty and an inadequate income to move to better housing, etcetera. I think a big part of that is that it's so wonderful that patients are saying to us, "This is what we need and we need you to advocate on our behalf."
"We're talking about fostering the conditions in which people thrive."
JK: There's been somewhat of a backlash on progressive action recently, more in the United States than in Canada, but some of that has bled over here. There's enough people in Canada who roll their eyes when they hear the words "social" and "justice" go together. Just this year in Alabama, Congressman Mo Brooks said "people who lead good lives don't have preexisting conditions" — that people who make good moral choices don't get sick. That speaks to some lingering attitudes around behaviourism. How do you think that impacts patients? How do you think that when we have had this focus on behavioural determinants of health, how does that impact the patient's behaviour and mentality going forward after that?
VT: We're seeing a lot of preventive health campaigns, for example like the Smoking Kills campaign in Ontario. We saw on our subways lots of signs that show the effects and impact of smoking on the body. I think for some people, these tactics can work, those who have good jobs or whose education and income level enable them to motivate themselves to quit smoking, for example. These type of tactics can motivate them to do so. But for a large segment of the population, I don't think these types of behaviours and these types of victimization tactics are really beneficial, because they neglect to look at the larger issues that impact why people engage in these behaviours in the first place.
For example, we know that it's those who are in lower-income brackets are much more likely to be obese, and they're more likely to smoke as well. Children who experience poverty are twice as likely to be obese as their counterparts who do not. I think when we say, when we just target the individual behaviours, we're neglecting to look at these systemic factors that make it stressful for someone who has a lower income to quit, and makes it more difficult for someone to want to seek out healthcare and to seek out access to the health services they need when they're made to feel as though they should be in total control of their own health.
JK: How does knowing all that inform your intentionality? How does knowing all that inform your practice and your attitudes towards care as a health provider yourself?
VT: I think even knowing all of this, sometimes I still get it wrong and I try to keep learning from everyone, from my patients and from my allied health colleagues. I remember one time I had a patient who came in and they were... This was a man in his 60's, and he'd come in because he had a fall. He told me that he was getting up in the middle of the night and had walked to his kitchen to get a glass of water and on the way he had tripped and then hit his head on the radiator and came in with a big gash. My preceptor and I, we sutured him up, and we made sure that everything was okay and then we said that he was good to go.
While I was writing his discharge papers, one of our nurses came up to me and said, "hey, I don't think we can let this man go yet. It seems like he was drinking before and he's been in the emergency department for a similar issue. I think we should get our social worker to see him." So even in this instance, for someone who thinks that they know so much about the social determinants of health and tries to incorporate it into practice, there are areas where we can misstep and we rely on our colleagues to keep us honest and to make sure that we're targeting upstream behaviours and upstream causes of our patients' illness in every step of the way.
JK: Did that teach you anything specifically when in that particular case? Was that a touchstone for you?
VT: I think for me this and other instances were an impetus to always be asking why. We all know that young child who is in the back of the car, they're asking a million and one questions about everything because they're so curious and they want to know why. I think it's important for us when we're in the clinic to not just stop when we get one answer that satisfies us. For example, someone says they're finding it hard to quit, or they're not able to eat a healthy diet or they're not exercising. There's always an upstream reason and there's always more to the story than I would say meets the eye initially.
"When we just target the individual behaviours, we're neglecting to look at these systemic factors."
So it's always important to question, to question everything and to be curious about our patients as people, and to think about what other stresses might be there in their lives. Of course we're certainly still taught in medical school and in school more generally about health behaviours. We know, for example, that for a smoker, if they quit their risk of getting like heart disease, heart attack and stroke drops to about less than half in about a year. I think it's still really important to counsel about personal health behaviours and every time I see a patient who does smoke or who does use illicit drugs, for example, it's certainly still a part of our conversation. But I think what's important is that we are moving away from just looking at these behaviours, both in school and in the clinic.
JK: And it's not just doctors, not just health professionals, social workers, lawyers, politicians... it's every single one of us, every Canadian has a role to play in how we shape the conversation, in how this movement plays out. Let's hear from Dr. Raphael one more time on how he plays that role. If you could just go from household to household, let's say you have the powers of Santa Claus, and as people are eating dinner together with their families or their friends, how would you change the conversation around what makes us healthy or sick? How would you tell the average, or as Justin Trudeau says, "the everyday Canadian," how to think about their own health and how we can make things better?
DR: Well, the entry we've used in the past, and we published numerous papers on this, was if we say to people, "what makes life good for you?" — when you ask the question in that way, people say, "oh, good jobs, kids doing well in school, having a good place to live, a safe neighborhood." And then once we get them there, we will say, "the things you've just mentioned are also the same things that determine whether you get heart disease or not, whether you get arthritis or not, whether you get diabetes or not." What has not been done, and Upstream has been the first organization willing to do it, is to say that all of these aspects of society that we recognize as being important are also the prior important determinants of whether you get sick and you die. Today, Canadians have increased their concern about income inequality, Canadians are increasingly concerned about housing prices, precarious work, but the connection has not been made.
JK: That's the next step we've got to keep working on. For doctors in clinics and other health professionals on the front lines, for our leaders making policies that shape the future of poverty and inequality in Canada. For you at home, at work and in your community, having conversations and impacting the society around you, and for us at Upstream as we do our best to tie it all together. We've got to keep working on making that connection, because when we really start to get it as a society, when we fully come to grips with the social, economic and political factors in what really makes us healthy or sick, makes us live a full life or die far too young, there may be no limit to how greatly we can improve the health and well being of our families, our communities and our nation.
Thanks so much for listening and for continuing to fuel this movement towards better health for all of us. If you like Upstream Radio and want us to keep making it, please be sure to subscribe, follow, like and review. Visit us at thinkupstream.net/donate to help us keep making the mainstream more upstream. To read, hear and see more from Dennis, Vivian, Brendan, Elizabeth and Patty, please visit us at our website and on our YouTube channel where you can find lots of great stuff with all of them. I've been Jared Knoll. Until next time, keep thinking upstream.