Health: Accumulating a Lifetime of Decisions

by Kevin Xu

The notion of health is all too often equated with medical care. For many of us, “health” undoubtedly brings forth the image of hospital scenes — the popularized and all-too-familiar setting of doctors and nurses crammed into operating rooms that we see in television shows such as Grey’s Anatomy and House. For others, health conjures images of disease-ravaged families from developing countries who have become the face of global health equity movements.

Health, however, means much more than merely the condition of not experiencing an illness or being ravaged by a disease. One of my friends, a GlobeMed activist and former senior editor for the Journal of Global Health, describes health as a matter of agency: To be healthy is to experience the conditions that allow us to thrive and live life to its fullest. To understand health is to understand much more than what is merely pathological: The condition of health is produced by a myriad of factors that span the sociological, psychological, economic, political, and biomedical. Thus any condition, idea, person, or thing that affects your ability to have control over your life is a determinant of your health.

Unfortunately, health care providers and most of our policymakers in Washington — including those responsible for recent American health care reforms — do not share this view.

The onus of providing health care continues to lie on institutions that operate on a definition of health that is, by and large, limited to medical care for the ill. The socially, politically, and economically determined conditions that both enable and limit one’s capacity to be healthy continue to be largely overlooked by those who control American healthcare policy. Preventive medicine and health literacy have almost always taken back seat to care for the sick, and the present economic hardships gripping the U.S. give us little reason to believe that the status quo is going to change any time soon.

But I think this mindset needs to be challenged.

Unless health care providers and policymakers address the social, political, and economic conditions that enable and limit our ability to make healthy decisions, we are failing to address one of the most important causal agents of disease incidence. Good health is the accumulative effect of an entire lifetime of mundane choices, decisions, and risks that may directly — or indirectly — affect our likelihood of developing disease and needing costly medical care, and it is egregious that this particular aspect of health is, all too often, ignored. The morals that we hold ourselves to, the value systems that we live by, and the ways in which we live our lives and perceive the world around us play an enormous role in shaping our health and making us prone to illness. The costly expenditures concomitant with health care that have drained the purses of governmental agencies and everyday Americans alike become a non-issue when disease is prevented at its onset.

That is not to say that public health interventions designed to promote healthy lifestyles and healthy decision-making have not already been implemented. S. Leonard Syme, a University of California at Berkeley professor and a well-known social epidemiology pioneer, dedicated his career to such public health interventions. “We have failed in this intervention enterprise. The issue is that we come up with risk factors and develop messages to give people, but people have lives to lead. The messages and the people rarely coincide,” says Syme in a recent interview in the journal Epidemiology.

I happen to have personally encountered what Syme is saying about a schism between “the messages” and “the people.” When I was in high school, I spent several months working on one of these social epidemiology “intervention” projects. I distributed pamphlets and lectured residents on healthy living and cancer prevention at several New York City Housing Authority public housing projects in Brooklyn.

The image of me — an Asian-American high school student from Long Island — attempting to help raise cancer awareness among a crowd of elderly, black housing project residents is a bizarre one. It was a haunting experience that not only felt futile but also awkwardly paternalistic. I remember being challenged by a resident at the Brevoort Houses in Bedford-Stuyvesant who exclaimed that the mammogram, because of its use of radiation, is the chief cause of breast cancer. “I went to college, you know,” he spat at me when I tried to reason with him.

Equally disconcerting was the time we offered a $20 monetary incentive for residents at the Cypress Hills Houses in East New York to participate in the intervention and donate a sample of urine and mouthwash for biomarker analysis. “They’re giving us $20 to spit and piss in a cup,” shouted a resident, one of the first to arrive, on his phone. Within 10 minutes, the community center filled up with over 30 people. The line stretched out the door. Few people seemed to be paying attention to the cancer prevention poster board in the corner of the room. And within half an hour, we ran out of money.

The habits of mind that are conducive to healthy living develop in the earliest years of our lives, and this makes Syme hopeful despite the challenges that have faced earlier public health intervention efforts. Says Syme: “I think the origins of disease and disorder can be found early in life … most of the risk factors we study in adults you can find in early life: blood pressure, obesity, respiratory function, and temperament — many things we care about are found early in life, and we know when we intervene with children, we can really make a difference.”

Indeed, early childhood education and universal preschool may be an efficacious yet easily ignored tool for preventive health care. “100 billion neurons at birth; neural synapses created and discarded at astonishing speeds early in life. At no other time in life does the brain evolve as rapidly as during the first years. The brain’s early development is crucial,” writes David Kirp in The Sandbox Investment, a book that provides a compelling argument in support of universal preschool. Syme enthusiastically recommends this book.

Undoubtedly, the notion of early childhood education and universal preschool as a vehicle for health care is one that is likely to encounter much resistance and be a tough sell among certain legislators and their constituents, especially during economically-trying times. But such a sweeping public policy change is not an entirely impossible sell either. For encouragement, one should look no further than the case of Matthew Myers, a lawyer renowned for his legal victories against the tobacco industry in the last two decades. Myers’ leadership in lawsuits and media campaigns against the tobacco industry have been given much credit for the reduction of adult smokers by nearly twofold since the 1960s.

Absolutely integral to any sort of social and political change is publicity. I had a chance to attend a Robert Wood Johnson Foundation-sponsored talk by Myers in June, an event at which I also met Syme. Myers repeatedly emphasized the importance of media campaigns and individuals to be engaged, to reach out to the public, to make the case. Of three hurdles to policy change described by Myers, the first mentioned is “uninformed policy makers and the public.”

The public health value of early childhood education — and its potential to foster healthy decision-making and healthy lifestyles — is one that has been overlooked for too long, and we, as college students, have the capacity and power in numbers to raise significant awareness to this cause.

Consider the case of student-driven global health work on college campuses that have become popular in recent years. Student-driven movements like GlobeMed, Student Global AIDS Campaign, Millennium Campus Network, Unite For Sight, and Face AIDS have made enormous impacts in their respective public health niches. Every year, thousands of American college students travel overseas on “brigades” to deliver medicines to developing countries and volunteer at rural clinics. Odds are that you may know someone who participated on one of these brigades or “alternative spring break” trips. Maybe you have gone on one of these trips yourself.

What if we could rally up some of this youth-driven energy for the cause of early childhood education?


Kevin Xu is the Editor-in-Chief of Columbia University-based publication, the Journal of Global Health