Square Peg Round Hole Fixing Our Approach to Health

[Music]

[Applause]

when you think of health and wellness

what comes to mind

maybe

it’s what you ate this morning

or your workout yesterday

or that doctor’s appointment last month

or all those times you’ve thought about

starting to meditate

but

what if i told you

that one of the biggest determinants of

your health

is your zip code

take a look at this map of the dc metro

area from researchers at vcu

you can see the differences in life

expectancy from 94 years in georgetown

to 78 years here in alexandria to just

67 years in trinidad in northeast dc

that’s an almost 30-year difference

within just five miles of each other

place matters

our health is determined by the ripple

effects

of sidewalks and parks

access to healthy food and adequate

housing clean air in safe neighborhoods

research shows

80 percent of our health is determined

outside the four walls of hospitals and

doctors offices

our health is driven by the places where

we live work learn and play more than

anything else

and yet

the vast majority

of our time our money and our attention

is devoted to addressing health and

wellness at an individual level

we turn to policy makers debating health

and what they’re really debating

is medical insurance

we turn to the media covering health and

what they’re really covering

is click bait recipes and workouts

all of this attention at an individual

level sends the message that you alone

control your health

so if you’re not healthy

blame yourself

and if someone else isn’t healthy well

shame on them no wonder then that when

we’re asked to think of health and

wellness

we think of our personal behaviors

no wonder then that of the 3.8 trillion

dollars spent on care in this nation

just 3 percent goes to support

population level public health efforts

like jamming a square peg into a round

hole like my daughters are trying quite

unsuccessfully to do in this picture

there is a fundamental mismatch

between the individual level at which we

think about and try to improve health

and the population level at which health

is actually determined

and this mismatch

it’s hurting us costing us and even

killing us

life expectancy in the u.s has gone down

in four of the last six years

health care costs have risen six-fold in

the past 50 years

we faced stark health disparities by

race and income and zip code and we were

woefully unprepared for covid19

covid19 pressure tested many of our

systems from contact tracing and

surveillance to public health

communication and policy

and many of these systems failed because

we haven’t focused on or invested in

strengthening systems

and it’s not unique to covid take almost

any health issue and we expect

individuals to make healthy choices

without creating healthy systems

let’s look at obesity

we weight shame and we beat ourselves up

for slipping up on the most recent fad

diet

at the same time we fight tooth and nail

against policies that would limit

portion sizes or tax sodas or change

zoning laws in ways that would make

healthy food and safe green spaces more

accessible to low-income and minority

communities

so that’s a lot of gloom and doom

for a talk that’s supposedly about

health and wellness

what can we do about this mismatch right

where are our round pegs

the good news and yes there is good news

is there are plenty of examples of what

can work

of how all of us can better match our

solutions to the population level at

which health problems are produced

but before we get into that

let’s talk a little bit about what

population level thinking and solutions

even looks like

one of the first things i learned as an

engineering major in college was to

always take a few steps back

and examine the system as a whole

but it’s not until i got into public

health and heard the upstream downstream

parable that i really understood what

this looks like

the story goes like this

a couple is fishing on a riverbank and

all afternoon they see people struggling

in the current and rescue them one by

one

finally they go upstream

where they discover an unprotected

overlook where people have been falling

in

they realize that if they could put up a

protective barrier

and post some warning signs they could

prevent everyone from falling in

instead of rescuing folks one at a time

after they’re already drowning

protective barriers and warning signs

are just two examples of the kinds of

systems changes we focus on in the

public health field

we spend our days thinking about things

like

designing neighborhoods more conducive

to exercise

reducing air pollution to prevent asthma

attacks

pursuing policy changes to ban false

marketing by cigarette companies

and redesigning cars and roads to

prevent injury

so

what do all of these have in common

they improve the health of entire

populations

not a single person

they change systems

not individuals

and they prevent illness before it

occurs

not treat it after the fact

so now you know what population level

solutions look like

but i suspect you’re thinking

i don’t design neighborhoods or roads

what am i supposed to do about all this

here’s what you can do

put down the square peg

pick up the round one

individual level approaches to health

are not the answer

but each of us individually does have

the power

to shift

from individual level thinking and

solutions

to population level thinking and

solutions

so what are those round pegs that you

can start picking up and using today

let’s get into it

round peg solution one

broaden your perspective

let’s stop blaming and shaming and

consider how to prevent poor health

outcomes at their root

the next time you find yourself judging

yourself or someone else for what

appears to be a personal health choice

ask yourself

what else might influence a person’s

choices

consider systems level factors

especially their physical and social

environment

the influence of policies and the role

of powerful institutions

let’s stick with our obesity example

from earlier

consider a neighborhood where fast food

and junk food are around every corner

consider a country where billions in

farm subsidies flow to support

production of corn and soybeans used in

processed foods

consider a food and beverage industry

that does everything in its power to

weaken dietary guidelines and manipulate

research

also ask yourself

what factors might lead someone to poor

health even if they did make healthy

choices

consider the impact of decades of racist

policies from housing to criminal

justice to education

and generations of poverty due to unjust

economic systems designed to keep the

poor poor and make the rich richer

the ultimate point

is that systems shape

choices

and by designing systems differently

we can make the healthy choice the easy

choice for all people

round peg solution two

change the systems you control

to improve health for the populations in

your life

you might think there are no systems you

control or populations you influence but

think again

does this look familiar

instead of expecting those you live with

to magically make healthier choices

you can redesign this system

to make the healthy choice the easy one

for everyone in your household

move the junk food and the sodas to the

back to the drawer to wherever will make

them harder to grab on a whim

on the flip side move fruits vegetables

and other healthy items out of drawers

where they’re out of sight and out of

mind

into places where they’re easily visible

and change how you prep and store them

so they’re quick to grab of course

redesigning this system

in this way

requires access to healthy foods which

not everyone has

but i share this as one example

of a systems level population level

change that might be entirely within

your control

and i hope it’s just the start to

thinking about broader systems and

populations

because your home refrigerator isn’t the

only system you control and your

household isn’t the only population you

can influence

for example

think about

integrating physical activity into your

meetings and other gatherings to get

everyone present moving

or consider getting involved in a

community garden to improve health and

environment for your entire neighborhood

round peg solution three

raise your voice

organize and advocate to change the

systems that are out of your control

make your voice heard and elevate the

voices of those who aren’t usually heard

the los angeles unified school district

increased its local purchases of fruits

and vegetables from nine percent to 70

percent of its 20 million dollar annual

produce budget

they did this through the good food

purchasing program a policy the local

food policy council developed and

advocated for that asks institutions to

sign a pledge to buy food that’s local

sustainable

nutritious supports workers and protects

animal welfare

the policy’s success has led to it being

replicated by school districts local

governments and other institutions in 16

cities across the country that

collectively spend one billion dollars

on food each year

this is the power that communities

coming together and raising their voice

can have

to advance systems changes like this you

can get involved in neighborhood

organizations city councils and school

boards

you can vote and campaign and donate to

support candidates and organizations

that pursue these kinds of systems

changes whether that be around food

access affordable housing or any number

of other upstream factors that have a

huge impact on our health and well-being

look at the end of the day

continuing our fruitless efforts to

force our individualistic square peg

solutions

along with trillions of dollars into a

round hole

is leaving us with worse health and

higher health care costs

listen i know we’re an individualistic

society here in america

we want to pull ourselves up by our

bootstraps and manifest our way to

health

but that approach to health is all wrong

there are too many broader forces at

play

our health is driven by the policies

environments and other systems

in the places where we live work learn

and play

so

take a look

around every room

and every building

and every neighborhood and community

you’re a part of

and try to spot these broader forces

put down the square peg

pick up the round one

put down single person solutions and

pursue population level solutions

instead

put down your efforts to change

individuals and change systems instead

put down after the fact treatments and

prevent illness instead

you have the power to make this shift

broaden your perspective

change the systems you control

and raise your voice

armed with these three round pegs

i hope we can all go out into our homes

our workplaces our schools our

communities

and meet our population level health

problems

with population level systems level

preventive solutions that leave everyone

smiling

and cheering

thank you

you