Re-Thinking Health Part 2: The Rhetoric and the Reality

Imagine for a moment you are attending a health-related conference, sitting in a large room with many hundreds of other people, listening to the keynote presentation. The speaker begins her presentation by asking, “Do you consider yourself to be healthy?” She pauses for a moment or two and continues. “Please raise your hand if you think you are healthy.”

What did you think about before you decided whether to raise your hand? What does it mean to be healthy? What if you turned and looked at the people sitting next to you? Could you determine whether you were more or less healthy than they were? How would you go about deciding that? Maybe by surmising if they were older, younger, taller, shorter, fatter, or thinner, or if they had more or less hair than you — or were dressed better or worse?

What would you ask if the presenter told you to jot down three questions to help you determine who was healthier? Maybe how much did they exercise, drink, or smoke? What was their diet like? How about their blood pressure, cholesterol, and body mass index? What does it mean to be healthy?

A 25-Year Quest to Discover the Meaning of “Health”

I have been keenly interested in this question for 25 years or so as I studied exercise physiology, nutrition, and health education. Over the past quarter century, I have had the great fortune to work with people in many walks of life to help them improve the quality of their lives. I have also had the considerably less than good fortune over the same time period to be diagnosed with multiple sclerosis and to have learned about health from an altogether different perspective.

Before my attack, I ran marathons, participated in triathlons, and played competitive racquetball. After the attack, I was forced to teach myself how to walk again, and now I need assistance climbing stairs and stepping over curbs. What I have discovered through this journey is that, although everyone seems to be talking about health, there is actually very little agreement and lots of confusion about what it really is — much of it, perhaps not surprisingly, based on the kinds of outdated scientific understandings Dr. Rosie Ward and I discuss in the first part of our new book, “How To Build A Thriving Culture at Work,” and in this freely available eBook titled “What’s Science got To Do With It?”

In “Re-Thinking Health – Part 1,” we examined current definitions of health and discussed how they don’t do justice, or even necessarily apply, to the reality of the human experience. In fact, we proposed that these definitions can actually increase people’s anxieties about their health. And we further examined how, even when health is defined as more than just the absence or opposite of disease, it is still often envisioned as some “optimal” or “perfect” or “complete” state that can be achieved (although in reality by almost nobody) if we just try hard enough. In Part 2, we would like to extend this discussion about the “realties” of human health from another very important and often overlooked perspective.

The Rhetoric

The emphasis on personal responsibility for health (among other things) is as American as baseball and apple pie. Traditional wisdom tells us that the problems with our healthcare system are largely due to people’s “unhealthy” behaviors and similarly that the problem with the “health” of organizations is that employees don’t exercise, don’t eat enough fruits and vegetables, and don’t get their cholesterol checked regularly. One well-known wellness book even made the nonsensical claim that the most common health problem facing our nation is “I-Don’t-Care-Itis” — referring to the supposedly multitudes of people who don’t care about their health and are not interested in improving it.

As we did in Part 1, we suggest here that this conceptualization of health is a misleading one at best — and in fact one that potentially engenders significant negative consequences. Although a truly holistic perspective on health does not ignore personal responsibility, decades of research clearly demonstrate that in many situations, personal factors may not be the actual causes of disease but rather the consequences of the real underlying causes. In an excerpt from his masterful work, “The Status Syndrome: How Social Standing Affects our Health and Longevity,” the world’s leading expert on the social determinants of health, physician and epidemiologist Dr. Michael Marmot, tells a story that helps to clarify the issue.

The story comes from a novel by Joseph Conrad about a revolution in the Latin America country of Costaguana. A rich, romantic young man Senor Martin Decoud finds himself isolated on an island during the revolutionary turmoil. Alone and cut off from the world, he ends up taking his life with his own firearm. Marmot explains the significance:

“To be true to my profession, medicine, I must confess that had a coroner found the body and heard the story, I would have recorded the cause of death as suicide by firearm… Conrad can distinguish causes from consequences even if we in the medical professions get a little confused. The cause of death was isolation. The consequence, the mode by which Decoud shuffled off his mortal coil, was indeed a self-administered shot to the chest from his own gun.”

The Reality

So, what does this have to do with our “Re-Thinking Health?” It is widely acknowledged that poverty is the single biggest risk factor for poor health. It is easy for most of us to envision how people living in abject poverty, without the basic essentials, suffer immensely in terms of both mortality and morbidity. But there is much more to this story than initially meets the eye, and it has powerful implications for how we address employee wellbeing. The causes of disease and premature mortality for people in abject poverty are easily identified and very different from the reality in developed countries such as the United States. Without adequate nutrition, sanitation and shelter, millions of people in underdeveloped nations are afflicted with and die of starvation, dysentery, and malaria. For most people living in countries such as ours, these dire consequences of abject poverty have all but been eliminated. But this does not mean that social and environmental factors have therefore been erased or even minimized as underlying causes of morbidity and mortality. Dr. Marmot, explains:

“We are dealing with the diseases people get when the society is rich enough to have dealt with malnutrition and poor sanitation: heart disease, diabetes, mental illness. These used to be labeled wrongly rich people’s diseases.”

In “The Status Syndrome,” Marmot documents decades of studies from all over the globe that consistently show that there is what he refers to as a social gradient in health. The final report of the World Health Organization Commission on Social Determinants of Health published in 2008, of which Marmot was the chairperson, presented the conclusions this way:

“The Commission takes a holistic view of the social determinants of health. The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives — their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities — and their chances of leading a flourishing life. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of the health inequities between and within countries.”

For critical emphasis, please note the final line of this last paragraph:

“The structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of the health inequities between and within countries.”

It is truly eye opening to peruse some of the relevant research findings from the past decades of Marmot’s work:

  • For each mile traveled on the subway from downtown Washington D.C. to Montgomery County, Maryland, life expectancy rises about a year and a half.(a 20-year difference from first to last stop – about 30 miles)
  • The higher the educational level reached, the longer people are likely to live and the better their health is likely to be.
  • Academy Award winning actors and actresses live on average four years longer than their costars and actors who were nominated but did not win. (This is about the same life extension that would occur if death from heart disease were reduced to 0.)
  • In industrial, office-based jobs, men at the bottom of the office hierarchy have (at ages 40-64), four times the risk of premature death of the administrators on the top of the hierarchy.
  • The greater degree of income inequality in a country, the higher the infant mortality rate and the lower the life expectancy even after taking the country’s average income into account.
  • Countries with high degrees of income inequality have higher homicide rates. The same is true for cities in the United States and also true for neighborhoods within big cities such as Chicago.
  • People whose jobs involve high demands and low control have a much greater risk of heart disease and depressive symptoms than those in jobs with more control.
  • Married people have lower premature mortality than single people.
  • Despite considerable westernization of diet and lifestyle, continued widespread cigarette smoking and increasing blood cholesterol levels in Japan, rates of heart disease are low and going down, not up.
  • Japanese people who migrated to Hawaii and then California had increased heart disease rates the farther they went from home, but this was independent of plasma cholesterol, blood pressure, and smoking patterns.
  • Whether they are rich (such as Japan) or relatively poor (such as the province of Kerala in India and the country of Costa Rica), societies that are socially inclusive have good health.
  • Men with the most control over their work conditions have half the risk of heart attacks as men with the least control, independent of smoking, cholesterol, blood pressure, and weight.
  • Traditional biomedical risk factors such as smoking, cholesterol, blood pressure, blood sugar, etc., account for less than one-third of the social gradient in mortality from heart disease.
  • The lower the social position, the higher the risk of heart disease, stroke, lung diseases, diseases of the digestive tract, kidney diseases, HIV-related disease, tuberculosis, suicide, and other “accidental” and violent deaths, even after traditional risk factors are taken into account.

Perhaps what is most particularly striking about this social gradient — what Marmot refers to as “The Status Syndrome” — is that it operates independently of traditional risk factors and absolute levels of wealth, within and between countries, and across gender, age, and racial lines. Like the poor soul on that desolate island, our physical and mental health are deeply affected by the context of our lives and specifically by how we compare to those around us in terms of our social connectedness and our ability to fully take part in the society in which we live. Although the diseases that people suffer and die from in underdeveloped nations differ from those in wealthier nations, the process in “advanced” countries such as ours has much more in common than it might seem at first blush. We know that with infectious disease, anything that weakens the host increases the likelihood of getting sick — so too it seems with the diseases that plaque more affluent, developed nations. Marmot summarizes the research findings:

“The circumstances in which we live — that foster autonomy and control over life, love, happiness, social connectedness, riches that are not measured by money — affect illness. It is precisely because these benefits of life are doled out unequally in society that we have inequalities in health and death. Life and death are not opposites; they are intimately related.” …These social inequities in health — the social gradient — are not a footnote to the ‘real causes’ of ill health in countries that are no longer poor; they are the heart of the matter.”

The power of this finding is further illustrated by the following chart:

Determinants of Population Health

The focus on personal responsibility notwithstanding, we clearly see that less than 25% of health disparities in the population is actually determined by individual health behaviors while the overwhelming majority of health disparities relate to factors involved in the “Status Syndrome” as described by Marmot.

Highly respected physician and author Nortin Hadler summarizes the reality in his powerful book “The Last Well Person: How to Stay Well Despite the Health-Care System”:

“At least 75% of the hazard to longevity can be captured with measures of socioeconomic status (SES) and job satisfaction. Socioeconomic status overwhelms and subsumes all the measured biological risk factors for all-cause mortality as well as most other mortal and illness end-points. SES is a measure of the kind of neighborhood in which you live and the context in which you are employed. For the disadvantaged… adjusting cholesterol and screening for cancer can do little to alleviate the mortal hazard of their situation in life.”

Applying the Reality

So let’s see how this reality plays out in our approaches to workplace wellness. While there has been much lip service paid recently to “holistic” approaches to health and to addressing work “culture,” the vast majority of workplace wellness interventions still focus on trying to get people to change their individual lifestyle behaviors (exercise, weight, nutrition, stress, smoking, etc.) utilizing 20th century, animal-research derived, behavior modification techniques — the efficacy of which for humans have been thoroughly refuted by many decades of research.

Of course this approach also flies directly in the face of the literature we just reviewed. Trying to effect individual health-behavior change in an “unhealthy” environment using interventions that reduce the autonomy shown to be critical for people’s health is doomed to result in marginal change at best. And with engagements levels of the U.S. workforce at around 30%, what the real work is that needs to be done should be crystal clear!

In spite of this reality, we seem to have a propensity for slipping back to the kinds of limited health concepts that we have exposed in this two-part series. In a recent webinar I attended, a leading authority in the workplace wellness industry showed a graphic similar to this one (fonts and colors have been altered to protect the innocent) to demonstrate what a “new” updated conceptualization of health might look like.

PhysicalHealthArrow

According to the speaker, the employees on the far left of the continuum (who were referred to as “outliers”) had reached some extraordinary level of health. The suggestion was that the focus of our efforts for helping should be dedicated to: 1) studying what these people had “done” to achieve this state, and then 2) convincing others to emulate their behaviors.

Hopefully, our discussions so far can help us begin to understand how our stuckness to this type of mechanistic, reductionist, biomedical, linear, cause-and-effect conceptualization causes us to miss the forest for the trees. See if you can identify some of the issues, by considering the following questions as you review the graphic:

  • Can only people without illness or risk or chronic disease have high energy and capacity for performance? Can’t people at risk or with illness or chronic disease have high energy and capacity for performance? (For example, where would I, with a diagnosis of multiple sclerosis, fit in this scheme?)
  • What does it mean to be at risk anyway? At risk for what? Who is not at risk?
  • Given what we have learned from Chaos and Complexity about cause and effect in complex systems, (for more details see “What’s science got to do with it?”, but for now think about the weather as opposed to a machine) what is the likelihood that we will be able to figure out exactly or even nearly why some people ended up with an illness or a chronic disease or became outliers while others did not?
  • Similarly, if the outliers created their optimal state of health, does that suggest that anyone with an illness or at risk or with a chronic disease caused his or her respective health problem?
  • Finally, given the eye-opening research on the social determinants of health, how much of the outlier’s good health can be determined by examining his or her individual health behaviors anyway?

When we combine the enormous implications of the scientific discoveries of the 20th and 21st centuries with the powerful findings of the research on the social determinants of health, we begin to understand how inextricably interrelated organizational and employee wellbeing really are. If organizations find that employees are struggling with their health and wellbeing, they might do better to look at how the society in general and the organization specifically are contributing to the employee experience rather than automatically jumping to the conclusion that what is needed are more initiatives that attempt to pay, prod, coerce, and punish employees into changing. We hope that “Re-Thinking Health” can be a vehicle for beginning this process.

Jon Robison, PhD, MS, MAJon is an accomplished speaker, teacher, writer and consultant. He has spent his career advocating that health promotion shift away from its traditional, biomedical, control-oriented focus, with a particular interest in why people do what they do and don’t do what they don’t do. Jon has authored numerous articles and book chapters and is a frequent presenter at national and international conferences. He is also co-author of the book, “The Spirit & Science of Holistic Health — More than Broccoli, Jogging and Bottled Water, More than Yoga, Herbs and Meditation.” This work formed the foundation for one of the first truly holistic employee wellness programs — Kailo. Kailo won awards in both Canada and The United States, and the creators lovingly claim Jon as its father. Contact Jon at: jon@salveopartners.com or jonrobison.net.

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