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The Challenge of Addressing Bad Behavior

On the roots of the choices that can undermine health.

Key points

  • Structural forces like racism and economic inequality are just as central to health as individual choices.
  • The idea of individual choice can be used to distract from structural health drivers, so it's hard to examine.
  • Biology, genetics, and broader structural forces likely all play a role in public health.

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.

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.

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, it is when we feel most sure that we have a responsibility to check our assumptions, revisit core ideas, and 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 that 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 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. 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 and 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.

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.

A version of this post also appears on Substack.

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