Can we choose to be healthy? Standard wisdom says yes, we can, by forswearing fatty snacks, keeping fit and otherwise living prudently. Time and chance happen, but we can slow the clock and better our odds; we're thus responsible for much of what ails us.
Corporate wellness programs and government-sponsored campaigns against smoking, overeating and sedentary living are becoming all the rage. They're public health's main response to cancer, heart disease and other serious health problems. Michelle Obama's "Let's Move" campaign against childhood obesity emphasizes breastfeeding, healthy meals and participation in sports. A recent report from the Robert Wood Johnson Foundation's "Commission to Build a Healthier America" offers up photos of fit 30-somethings in clingy spandex, wearing helmets as they ride bikes. They presumably avoid smoking, sip wine in moderation and, should they find each other enticing, enjoy safe sex.
These things are all well and good, but something's missing from this story -- something most public health leaders are too timid to talk about. It's the outsized influence of economic and social inequity -- the main driver behind premature death and myriad medical problems. Take the subway several or more stops in a major city -- or take a bus from an impoverished Appalachian town to a luxury mountain resort -- and you'll pass through places with average lifespans a decade or more apart. You'll ride through some neighborhoods with infant death rates lower than Switzerland's -- and others with rates that rival Honduras'.
The eating, smoking and other lifestyle choices that wellness campaigns target account for less than half of the differences in average lifespan that you'll encounter on your journey. The 1990s mantra, "it's the economy, stupid," explains much more -- variations in wealth and income are the main driver behind local differences in longevity.
Researchers have made large steps toward figuring out why. Money insulates us from life's wear and tear -- from worries about getting by (paying the bills, the mortgage or rent and the kids' tuition) and from routine annoyances like rough commutes and rude bureaucrats. Wealth empowers us to live with less fear -- of job loss, home foreclosure and other financial calamity. And the privilege and position that come with wealth confer a heightened sense of personal control. Assistants fret about asking the boss for time off for parent-teacher meetings; it's not the other way around. The priciest hotels, food stores and fashion boutiques treat their customers better; so do the flight attendants in first class.
Life's anxieties and abrasiveness have a physiological impact. Stress responses release cortisol, suppress testosterone and influence myriad other biological systems. Blood pressure rises, immune functioning ebbs, sleep becomes more difficult and mental focus diminishes. Our risks for cardiovascular disease, cancer and other life-shortening illness and injury correspondingly rise.
Even the lifestyle "choices" that wellness campaigns target are shaped by socio-economic standing. Michelle Obama's "Let's Move" campaign and the Robert Wood Johnson Foundation's "Commission to Build a Healthier America" concede this, up to a point. They acknowledge the problem of "food deserts" -- low-income areas with fast-food outlets and liquor stores but no places to buy healthier fare -- and they note that violent city streets and parks discourage jogging, biking and other efforts to keep fit.
Public health leaders have begun to take aim at these obstacles. They're rewarding food sellers for opening in poor neighborhoods, pushing for better policing of parks and streets and making health impact part of urban planning. But these efforts ignore deprivation's broader impact on behavior. When paying the rent or the mortgage is a daily struggle, when money for food or the heating bill is an iffy proposition, and when staying alive on mean streets is a matter of doubt, taking the long view of lifestyle and wellness becomes more difficult. Not only do the down-the-line benefits of eating wisely, keeping fit and eschewing tobacco seem far-removed, the quick pleasures of microwave pizza, a cigarette or a furtive tryst offer escape from the chronic anxieties of coping with life on the edge.
And more of us are being pushed toward the edge -- or over it. The number of Americans living in poverty rose by 2.6 million last year, to 46.2 million, according to the Census Bureau. The "Great Recession" and its miserable aftermath have hollowed out the middle class, taking away the livelihoods of millions and slashing home values and retirement funds. The recession has been more catalyst than cause for loss of jobs to low-wage competition overseas and "smart" technology at home. It's thus more catalyst than cause for our country's widening inequality.
The avowed goal of the U.S. Department of Health and Human Services is to make America "a nation free of disparities in health." What's much more likely is that disparities in lifespan and other health measures will widen as the effects of rising poverty, middle-class collapse and growing inequality play out in people's lives. And for the first time in our country's history, we could even see declining lifespans. That's what happened in Russia during the 1990s, as crony capitalism and disappearance of jobs that paid a living wage turned the lives of many millions into an unrelenting struggle to survive.
So it's past time for our leaders to put caste and its consequences -- and the corrosive effects of a sinking economy -- at the top of America's health agenda. Timidity on this front is neither justified nor necessary. On the streets and in public discourse, inequality has sprung forth as a national issue. Its devastating health consequences make it a matter of national urgency.
Employment that repairs infrastructure and lifts jobless families from despair, education that prepares people for tomorrow's possibilities and entrepreneurship that anticipates and delivers on these possibilities ought to be front and center on our health policy agenda. We can indeed choose health and wellness, but our most important choices are those we must make together.
M. Gregg Bloche is Professor of Law at Georgetown University and author of "The Hippocratic Myth: Why Doctors Are Under Pressure to Ration Health Care, Practice Politics, and Compromise Their Promise to Heal."