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