The problem of bad behavior

On balancing public health’s focus on the structural drivers of health with the role of individual behavior.

I was trained as a doctor and worked as a primary and emergency care physician. While it has been years since I have practiced medicine, many of my friends—as the saying goes—are doctors, and this second phase of my professional life keeps me in contact with physicians who also work in the public health space. I suspect that many of them feel in their heart of hearts something that many doctors, particularly those working in primary care, feel—that much sickness and death could be prevented if people just made better choices.

Consider the reality of working in emergency departments. Day in and day out, ER personnel witness the same mishap-driven injuries and deaths. Here, again, comes someone needing stiches after getting in a fight. Here comes the week’s third driver suffering from grievous injuries because someone drank and drove. Here comes yet another laceration caused by some ill-advised home improvement project gone wrong.

Then there are the more chronic issues a doctor faces. There are the challenges associated with obesity, from heart disease to arthritis. There is lung cancer caused by smoking. There are the STDs spread by lack of proper protection and testing. The doctor sees in individuals what we in public health see in populations. And while we know that the causes of disease are complex, that blaming illness on lifestyle can be an oversimplification at best and stigmatizing at worse, it can be hard, when confronted with the sheer weight of the disease burden, to not for a moment think, “If only people did not make such bad choices…” Surely the stiches could be avoided if the fight had been avoided too. Better behavior with respect to alcohol could prevent untold suffering. Obesity-linked diseases could be reduced if people chose to eat better. The dangers of cigarettes are well-known and yet many people still smoke. More condom use could reduce the spread of STDs. These realities make it possible to think that health is disproportionately a matter of behavior. But is it?

In my academic and professional life, I have been, broadly defined, a social epidemiologist, concerned with the social structures that generate health. I began my career with the perspective common among doctors that behavior is the key driver of much poor health. From there, through my study of population health, I began to see the bigger picture of how structural forces shape health. I saw that health is a product of the world around us and that forces like education, neighborhood, opportunity structure at birth, social networks, structural racism, and economic inequality are just as central to health—if not more—than any choices an individual can make. My book Well: What we need to talk about when we talk about health was an effort to distill the influence of these factors to support a wider understanding of their importance to the health of populations.

It is possible, then, that this is the answer—that the health of individuals is entirely mediated by structural forces and that the role of individual choice matters little, if at all, in the context of these forces. After all, how healthy can our choices be if we live in unsafe neighborhoods, if we cannot afford nutritious food, if we face marginalization due to our identity, if we lack access to a good education? Our choices would be nominally our own, but the options between which we could choose would be curtailed by circumstance. If we in public health are sure of anything, it is this—that structural forces are an ineluctable influence on health, and that health cannot be understood outside of this influence.

Yet, as I have argued often in this newsletter, it is when we feel most sure that we have a responsibility to check our assumptions, to revisit core ideas, to constantly analyze that which we take to be self-evident. I have long admired papers like this one and this one which try to determine what matters most for health, whether it is individual behavior or something more fundamental than that—whether it is, centrally, the world we live in that matters most. In public health, it can be challenging to revisit these questions because a focus on individual behavior has so often been used to distract from the structural drivers of health. How often have we heard a politician object to a measure which would shore up the foundations of health—by strengthening the social safety net, say, or placing a tax on harmful substances—with the words “It is a matter of personal responsibility”? Given the role this perspective has played in undermining progress and scapegoating individuals for their poor health, it makes sense that we might hesitate to engage with how behavior shapes health outcomes.

But just because something can be used in bad faith does not mean it cannot also reflect a fundamental truth about the world. And, in addition to literature which engages with the structural drivers of health in society, there is another stream of literature that explores how biology, and genetics specifically, contributes to behavior. There is a fair bit of literature that has documented, for example, the genetic basis of substance use behavior, as well as of some behavior (e.g., violence) that we might otherwise just consider a “personal choice.”  And that is not to speak of perhaps harder to define concepts like personality, or simply the making of bad choices.

The sophisticated reader of this column will likely come to the conclusion, of course, that no single factor is fully responsible for health behavior. Biology, genetics, and broader structural forces all have a role to play, to greater and lesser extents, in shaping the choices we make about health. To engage with one factor is not to deny the influence of the others, nor is it to pass a values judgement about the intersection of these forces with the behaviors that drive health outcomes. Yes, certainly, context matters, but all contexts being equal, there also remains bad, ill-conceived behavior that leads to poor health. Given the role of genetics in shaping a range of other physiological and psychological factors, there is undoubtedly some genetic or biological component that pushes some people to act in particular ways that are harmful to their health.  

I revisit this now because, first, I have been interested, as the organizing principle of this series of essays, in articulating the foundations for a post-war practical philosophy of health. This philosophical framework must include accounting for how we deal with individual choice within a context of complexity. Public health has had much success in centering in the conversation about health an engagement with structural forces. But we have also arguably been a victim of this success, when this engagement—necessary as it is—has at times crowded out discussion of the role of individual behavior in shaping health and the ways in which behavior is shaped by biological and genetic factors. Given that this influence is supported by a robust body of data which will likely only grow, a public health that does not engage with these factors is a public health that is working with one hand tied behind its back.

I have been thinking of this in the context of the recent flurry of articles about new weight loss drugs. These drugs target the chemical pathways which regulate appetite, helping people to feel full faster, making it easier to eat less. These medications have been met by an absolute deluge of writing, including some that I found quite good and reflective and some that I found baffling in their seemingly single-minded focus on using the drugs to deal with a problem that clearly includes genetics, choices, and context, with drugs surely being only part of a complex issue.

Will the new weight loss drugs have an impact? Probably. They seem to work as appetite suppressants and as an influence on metabolic rates. Whether that impact is sustainable (and what happens when people stop taking these drugs) remains very much to be seen. The emergence of these drugs, then, is a microcosm of the broader issues of engaging with individual behavior, the biological roots of poor health, and contexts of complexity. On one hand, the hype about the drugs reflects how an overfocus on biology and individual choice can distract from the structural drivers of poor health—in this case, the many factors beyond personal choice which shape obesity in populations. The hype shows what public health has long been up against in trying to refocus the narrative on these upstream forces. On the other hand, these drugs (notwithstanding their risks and unknown long-term effects) do seem to work by engaging with real biological mechanisms which influence choices about eating. We in public health should not be in the business of ignoring this reality in our approach to disease. 

I sometimes think that social epidemiology, and public health in general, has not helped itself by insisting that everything is about context, ignoring the evidence that while context is important, there is much more at play. At the same time, it can be easier to invest in medications, like the new weight loss pills, that seem to address the biological drivers of choice and health than it is to engage with the structural forces that shape context.

So, we are once again faced with complexity, nuance, and the importance of thoughtful engagement with the full range of forces that shape health, including those which may not align with our preferred narratives. This, then, is a call for us to recognize that behavior, all of it, emerges from some combination of personal agency and choice, biology and genetic determinism, and the world we live in. If we are to improve health, it is our job to engage with all these factors. Engaging with personal choice, of course, requires persuasion, and the creation of reasonable limits on the bounds of choice (such as wearing a helmet while riding a motorbike). Engaging with biology and genetics may allow for opportunities for pharmaceutical and medical intervention. Engaging with the world we live in means the hard work of creating a healthier context for all. And it is all of these that are the foundational work of public health.

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Also this week.

This is the happiest weekend of the year, our convocation weekend where we celebrate our graduates. My letter to our graduates is here.