Table of Contents

In America we spend nearly twice as much for health care as any other nation. So why are we among the sickest people in the industrialized world?

We have built a medical complex capable of stunning feats. Doctors can repair our hearts by remote control through pencil-thin catheters, put us in an anesthetic trance and swap out our organs, and train viruses to plug DNA fragments into our genes. We are so awed by this system that we pay the 1.4 trillion dollar annual cost - about one-seventh of our gargantuan economy - with little complaint. The only problem with our health care system, many Americans seem to believe, is that there is not enough of it to go around. To many, the benefits of being able to go to a doctor are so great that lack of access to the medical care system is one of the great social injustices of our time.

But Americans don't seem to be obsessed only with being able to visit doctors and hospitals after we get sick. Americans have learned - in principle, at least - that it makes a lot more sense to prevent sickness than to treat it after it happens. In the last quarter century the U.S. has seen an explosion of health clubs, health food stores, articles on nutrition, health and fitness magazines, and health segments on television. Some of the television segments show the latest high-tech surgical procedures or research on rare and tragic genetic diseases, but many explain the health advantages of fish oil, or oat bran, or aerobic dancing. We just can't seem to hear enough about what makes our bodies tick, and what we ought to do to keep them ticking longer.

Our nation also has a vast - if often unrecognized - system of public health agencies to keep us healthy. Every state has a health department claiming a broad mission to maintain health and prevent illness in all of its citizens. Behind all of them is a phalanx of acronymic federal agencies (CDC, HRSA, AHRQ, SAMHSA, NIH) with equally ambitious goals of health for the entire nation. And they have local equivalents - health departments in cities and counties and even private nonprofit groups - with broad agendas for health.

What do we have to show for all this? We are an economic colossus, the wealthiest country in the history of the world, but our national vital signs are barely better than some third-world countries. According to statistics compiled by the World Bank, the U.S. ranks 31st among nations for age-adjusted mortality rate in women, below Slovenia and Costa Rica. Our infant mortality rate is 26th, more than twice that of Singapore and tied with Croatia and Cuba. We have more births to teens than over half of the world's nations. Our health statistics in America are gradually getting better, but that is hardly an accomplishment when other countries do so much better with so much less. The question will not go away: if we spend so lavishly on medical care and we care so much about our health, why are we so unhealthy?

Something is wrong about the way we are approaching health in the United States. We don't need another health care reform plan. We need a new way to think about health.

This book is our attempt to introduce that new way of thinking. We build on ideas that have been batted around among academics for years, but that haven't penetrated the national conversation, and then add some of our own. The basic concept is simple: just as poor sanitation caused infectious diseases in the 19th century, an unhealthy physical and social environment is causing major killers like heart disease, cancer, and AIDS today. And just as the solution to the outbreaks of cholera 150 years ago meant redesigning the industrial revolution's city infrastructure, the solution to epidemics of disease today will mean reshaping our everyday world.

The book is organized in three sections. In the first section we explain how and why we took a wrong turn in health in the United States and point to our everyday world as the key source of disease or health. In the second we show exactly how four features of our world - what we call "curve shifters" - exert their effect on us. In the third section we take up each of the leading killers of our time and discuss specific ideas on fixing our everyday world to tame them. More ideas will surely come from others.

This is not a book on politics, but if we want to fix our everyday world we will need to act politically. In the last chapter we discuss some of the politics of health in this country, and for readers who are skeptical that we really can change our everyday world, show that it is not terribly difficult.

There is nothing wrong with our obsession with health in America. It is just our perspective on the sources of disease and the way we spend money to prevent illness that is wrong. Although we Americans are the ones who are becoming sick, the fundamental source of disease is not inside us. Disease arises from the world around us. At the same time, our everyday world has the potential to be the most effective cure for our modern society's epidemics. To use it, though, we must start by rethinking our assumptions about what causes disease and health in our era.

As we have all been told, health care in the United States is in crisis. Insurance premiums are up and covered services are down. Employers are sinking under the weight of benefit costs. HMOs are denying people referrals to specialists. The number of uninsured has sailed well past 40 million, and public hospitals are closing. Medicare is insolvent and Medicaid is devouring state finances. The cost of prescription drugs is skyrocketing. While the total costs of medical care grow relentlessly, people feel they are getting less and less of it. Every politician seems to have a plan for fixing the system, but it seems no two can agree on anything, leaving more and more of us to fend for ourselves, defenseless against the ravages of disease.

An apparent island of calm in the middle of this growing national calamity is a woman named Gwen Longworth. Gwen is 58. She's large, solid, and matronly, dressing colorfully but not elegantly. She speaks rapidly and intensely, with relentless confidence about her children, her life, and her work, which is as a part-time psychotherapist and, it seems, full-time community activist. Her activism is Californian and eclectic, ranging from aiding Latino immigrants and serving as a District Governor for the Rotary Club to lying down in front of bulldozers to block commercial development of a wildlife area outside her town. Her family follows the same pattern: she has raised seven children, including two adopted Mexican immigrants and one foster child, and she estimates that she's housed about 500 exchange students over the last 25 years.

Gwen has withstood the health care crisis because her husband is a research analyst at a county college, a civil service job that brings with it the coverage that others can only dream of: as she explains it, 100% coverage of hospitalizations, 100% coverage of office visits for the whole family, and prescription drugs covered except for a $10 copay every three months. Which means that Gwen never has to wonder about where the money will come from for her doctor visits or the drugs she takes. And drugs are what the medical system offers. Every day Gwen takes two medicines (glyburide and Glucophage) for her diabetes, and one (Accupril) for her high blood pressure. For the arthritis in her knees she takes ibuprofen (an anti-inflammatory drug) and glucosamine chondroitin (an arthritis remedy sold as a nutritional supplement). She has a regular doctor whom she likes and visits every three months. Because of their insurance, Gwen doesn't worry about draining her life savings if her husband has chest pain or she finds a lump in her breast. If advocates of health care reform were to win every battle they fought, everyone would have Gwen's coverage - and the peace of mind that goes along with it.

But is the victory we want? Ever since she was a teenager, Gwen's been gaining weight. She passed 150 with her first pregnancy, kept gaining during and between her others, and is growing heavier still. Gwen is too confident and upbeat to lament her weight, but she has tried to stop gaining more - tried "everything…all the 'Great Diets' like Atkins and Pritikin," - and failed. More precisely, they all work, temporarily.

At 5 foot 9 inches and carrying 236 pounds, Gwen has a body mass index (BMI) of 36, enough to earn her the designation of Class II "morbid obesity" by the National Institutes of Health. As such, she has a high risk of dying from colon cancer or breast cancer. She's got a good chance of needing to have gallstones removed. She'll have diabetes for the rest of her life, even if she takes a mountain of glyburide, and even if starts injecting herself with hypodermics of insulin every day. Over time, her diabetes will likely cause problems with her eyesight (from cataracts to blindness from retinal hemorrhages), raw sores on her feet that refuse to heal (perhaps requiring amputation of a toe, a foot, or a leg), and a distinct possibility that failing kidneys will require her to finish her days tethered to a dialysis machine three days a week. All the health insurance coverage in the world and years of Accupril will not cure her high blood pressure. The combination of hypertension and diabetes means that before she even reaches retirement age she has about one chance in twenty of having a stroke and one chance in three of fatal or near-fatal heart disease. The arthritis in Gwen's knees prevents her from walking on the trails near her house, a loss of pleasure in life which she says makes her want to cry.

Gwen has wonderful health insurance and an abundance of health care. What Gwen does not have is health. And there is nothing our health care system can do to give it to her.

Cholera wasn't the only killer infectious disease of the industrial revolution; it was simply the most terrifying marker of an entire era dominated by them. In the middle of the 1800s, the new industrial cities in the U.S. were not only jam-packed, they were filthy, and full of garbage, dead animals, and sick people. In fact, in the disease-breeding grounds of Boston, Philadelphia, New York, and New Orleans, death rates reversed a long-term trend and increased 42% between 1813 and 1850.

Doctors didn't know much about the causes of the major diseases at the time. But they noticed that the poor died off quicker and younger than the rich, and they felt that their eating and drinking habits were "intemperate". The leading experts concluded that, as public health historian John Duffy writes, "the basic problem with the poor lay…in their lack of moral fiber". Sickness came from the package of dirty houses, dirty habits, and sin - all of which were the fault of the poor themselves. They had no one but themselves to blame for their diseases, and they would have to take responsibility for preventing them. The experts felt society's only responsibility to the poor was to teach them a combination of personal hygiene and resistance of sin.

But back in England, a strident reformer named Edwin Chadwick, who knew Snow and who served as Poor Law Commissioner, took an entirely different view. Over a three-year investigation in which he enlisted a small army of district health officers, Chadwick demonstrated the connections between disease and the squalid conditions in which the poor were forced to live and work. He brought attention to these actual causes of disease in 1842 by publishing The Sanitary Conditions of the Labouring Population. This was the era of Dickens, and although Chadwick didn't have Dickens' way with words, he described many horrid scenes:

"Of the 182 patients admitted into the temporary fever hospital…135 at least came from unpaved or otherwise filthy streets… Whole streets in these quarters…are without drains or main-sewers…and are so covered with refuse and excrementitious matter as to be almost impassable from depth of mud, and intolerable from stench…But dwellings perhaps are still more insalubrious…The doors of these hovels very commonly open upon the uncovered cesspool, which receives the contents of the privy belonging to the front house..."

Anyone living in these conditions, Chadwick claimed, would get sick and die. The poor weren't inherently different from the rich except for miserable conditions in which they lived, which they could not be held responsible for. In fact, he turned the morality theory on its head, writing that it was "these adverse circumstances [that] tend to produce an adult population shortlived, improvident, reckless, and intemperate, and with habitual avidity for sensual gratifications." To his readers who didn't care about the health of the poor, he argued that cleaning up neighborhoods would not just keep the poor alive, it would also make them morally stronger. He then proposed a truly radical idea: governments should take responsibility for fixing these problems - providing clean water, building sanitary sewers, removing animal carcasses and other refuse, and even assuring that sweatshops had decent ventilation.

When they heard his report, the Lords in the British Parliament, who were far from poor, politely buried it. They would have had to pay for sanitation with taxes - taxes that would fall more heavily on them than on those in the slums - and taxes were about as popular then as they are now. But six years later a reform government finally passed the Public Health Act, which while greatly watered down from Chadwick's proposals, established for the first time the principle that the government would take responsibility for protecting the health of its citizens.

Chadwick was put in charge of enforcing the new law, and because he was uncompromising and generally obnoxious, it didn't take long before he was bounced out. His ideas went much further, though. Three years after Chadwick published his book, a prominent New York physician named John H. Griscom came up with a local version, The Sanitary Conditions of the Laboring Population of New York, in which he made the same arguments. Around that time, people in cities in the U.S. began to demand better water, sewers, and cleaner streets, and cities began to provide them. Philadelphia got an extensive water supply using new cast-iron pipes by 1835. New York brought water from the Croton River in 1842 and Boston greatly expanded its water supply in 1848. The major cities followed these innovations by constructing sanitary sewers in the 1850s. Smaller cities and towns then gradually built similar water supply and sewer systems of their own.

Griscom and other physicians in the port cities of New York, New Orleans, and Boston, then used the success of the improvements in city water systems and Chadwick's ideas to forge a national sanitation movement. They organized a series of National Sanitary Conventions between 1857 and 1860, and institutionalized the movement after the Civil War as the American Public Health Association. In the beginning, they spent their time with minor reforms like drawing up standards for quarantine for cases of cholera and yellow fever, but as the movement gathered momentum they became more ambitious, taking on policies for safe water and waste disposal, solid waste disposal in cities, and ventilation of schools, tenements, factories, and public buildings . They went on to promote vaccination against smallpox and even ventured into policies on prostitution and venereal diseases. "The Sanitarian" was published in 1873, turning sanitation into a discipline of its own. By the 1870s the sanitation movement began to incorporate non-physicians, including leading businessmen and social reformers. Local and state boards of health grew in number, scope, and power. Toward the end of the 19th century the now-powerful sanitation movement further expanded its scope and took on - or aligned itself with movements for - social reform, including housing reform, control of air pollution, education reform, school-based health screening and treatment, workplace health and safety, and the abolition of child labor.

It must have been an exhilarating time. The "sanitary revolution" was just that, bringing on historic advances in health. Epidemics that had decimated entire cities were quelled and the routine infectious diseases that killed many people at young ages began to fade away. After having risen in the early part of the 19th century, mortality rates in major cities plummeted 55% between 1850 and 1915. Infant mortality dropped in parallel and life expectancy increased by some 25 years. What is most amazing is how much was done with so little knowledge of biology. What may have been greatest improvement in population health in human history was brought about without any successful cures for any disease.

These successes put the "moralist" view of disease in decline, at least for the time. As Duffy explains it: "Whereas sinfulness and lack of moral character were held to be largely responsible for poverty and disease early in the first half of the 19th century, increasingly the middle and upper classes began to recognize the role of environment in shaping people's lives…[S]cience held the possibility for solving all health problems. Rather than eliminating social problems by concentrating on improving the moral character of the poor, now it seemed the solution lay in improving the environment of the poor. "

Americans often bristle at the idea that our everyday world might shape how we behave. We believe - because we are Americans - that we control our destinies, that we can do anything, if only we have the intelligence, motivation, and grit. Our ancestors escaped societies in which someone born a peasant could only be a peasant. Triumph within a tough world is our collective history.

Psychoanalysis, as it has diffused into our popular culture, tells us that if people can only understand themselves and their problems they can overcome any obstacles to success and happiness. Self-help books are so popular that they rate an entire category of best-seller lists. Hollywood exalts heroes who rise from poverty and adversity. We admire the successful exceptions - the tough ones who master their environment - so much that we believe they represent the norm. We don't sympathize with the losers who are bogged down by their surroundings; they deserve what they get. We can choose (or choose not) to smoke, drink alcohol, eat French fries, or shoot each other. To suggest to most Americans that our environment influences these choices is an insult.

Renny Lemoine and Durel Richard are as American as they come. They are convinced that the movies, billboards, store advertising displays, and magazine ads don't do anything to them. They make their own calls in life. Other high school kids in a focus group were just as firm: "Who gives a damn who's smoking up there [on the screen]?" "No one can make you do something you don't want to do." Their fierce independence would be inspiring if it weren't so wrong. Cecelia Turner believes she should have the strength to overcome her surroundings, so when she sees that she hasn't she blames herself. It is heartbreaking to hear this woman of such extraordinary achievement say that when it comes to food, "I'm really bad."

As free and strong as we are in America, we are influenced by what we encounter every day. The tobacco companies understand this, or they wouldn't spend billions promoting smoking. The blossoming of the obesity epidemic in a nation of image-conscious overachievers is further evidence. The impact that any single feature of our environment has on a single health behavior might be small. But for our whole society, the effect is enormous.

Of course our environment doesn't control us. People do make decisions. The values and habits they bring from their families shape these decisions. Cultural differences between groups of people explain why some groups of Americans have healthier habits than others. But we now know so much about the prime dangers in our modern world (like smoking, drinking, and lack of exercise) that those among us with the extraordinary willpower to overcome their everyday world have already done so. At this point in our history, if we really want to be healthier we have to tackle the most important influence left - the world around us.

We inhabit a world that is man-made. We occupy buildings, travel through neighborhoods, shop at stores, watch video screens, and read magazines all created by humans. Our day-to-day environment isn't natural - it's designed. Since humans design this environment in a way that makes us sick, humans can just as well redesign it to help us behave in a healthy way. Governments and corporations change the world that surrounds us all the time for their own reasons and end up affecting our health one way or another. It's time for us to understand how the features of our everyday world affect us, and then to change them in an explicit, deliberate way so that we can be healthier.

In the long, hot summer of 1967, workers in the Bureau of Health Statistics in New York became alarmed about a wave of children plunging through the air to their deaths. New York had always seen tragic deaths from falls from apartment-building windows, mostly in curious preschoolers whose parents lost track of them for a moment, but in this sweltering summer as more parents left more windows open longer, the numbers of children smashed on the sidewalks hit a new peak. One patrolman later said dozens of children fell in his precinct every summer, and that he had personally picked up nine dead children in just one season . By the time the annual statistics were compiled for 1967, 61 children had died from falls out of buildings, enough to account for one fourth of all injury deaths in children under age five . And the distressed workers even found that some apartments showed up more than once in their falling children list.

The Health Department then asked hospital staff in the worst-affected borough, the Bronx, to start notifying them of all plunging children, and afterwards sent social workers to their families' apartments to investigate. In their summary report the typical child's family was poor, receiving a welfare check of $50 to $75 a month to support four or more children, and living in "a four- or five-room walk-up apartment [in a tenement, with]….many holes in the ceilings and walls, loose parts in the floor, broken windows, plumbing leaks, inadequate lighting, rats and other vermin" . The toddler - usually a rough-and-tumble boy - had climbed on a fire escape or near an open window and taken one clumsy step too many.

But the cause of the problem wasn't poverty and it wasn't just boys being boys. Children just as poor and just as curious who lived in the public housing projects in Bronx at the same time weren't diving to their deaths. So Health Department investigators also visited the housing projects found the obvious differences: instead of double-sash windows, casement windows that hinge on the side and don't open enough to fit toddlers easily, and instead of external fire escapes, internal fireproofing. The cause of the problem was the design of the buildings.

After an initial program to educate parents about the problem, the Health Department got a little more practical. They helped design simple window guards just for the sort of tenement windows through which children were falling. Then they put out to bid the job of manufacturing them, which brought the price down to about $3 each, and bought over 16,000 a year, giving them to 4,200 families living in high-risk buildings . They installed some and let families install others, later inspecting them to be sure they were installed correctly. Within two years, the "Children Can't Fly" program cut the number of children dropping to their deaths in the Bronx by half . Then in 1976 they went further, persuading the Board of Health to pass a law requiring landlords city-wide to install window guards in all apartments with small children . The number of children falling in Harlem immediately dropped 96% . Three-dollar window guards don't carry the same drama and excitement as open-heart surgery, but they can be a lot more effective in saving lives.

We spend our lives interacting with physical structures - not just windows and window guards, but also roads, cars, stairs, chairs, soda bottles, and candy wrappers - that shape how we behave, how healthy we are, and at times whether we live or die. Some influences in our modern man-made world are so hidden that we don't notice them, but for physical structures it is often just the opposite: because they are in plain view, all the time, we don't recognize how important they can be. 

To health experts who have known the facts about smoking for decades now it's idiotic for anyone to take up smoking, or for anyone who smokes to keep doing it. It makes perfect sense, then, to think that we can win the war against tobacco by educating people. When people know about these gory statistics, they won't pick up cigarettes, and smokers won't continue.

But what makes sense isn't always true. In the 1960s and 1970s the American Cancer Society, the American Heart Association, the American Lung Association, and many other public health groups tried to dampen smoking rates by trotting out scores of variations on two types of programs: counseling of adult smokers to quit and educating teens not to start in the first place. The programs employed every educational tool you can think of, including lectures, assemblies, discussions, demonstrations, posters, pamphlets, films, articles in school papers, visits by experts, and support groups, and they ranged in length from one week to several years. The educational messages were truthful and consistent, emphasizing "the health, social, and/or economic costs of smoking". But in 1976, when the American Cancer Society asked for an external review of these programs, they learned that among adults "anti-smoking campaigns have had little reported effect on smoking behavior" and that "most attempts to influence the smoking behavior of the young have had little success." Some of the programs made people adopt more negative attitudes toward smoking but some didn't even achieve that. The report from the review even suggested why the programs were failing. "The majority of the programs seemed to accept the premise that man is a rational being and that he will act in his own best interest."

Educational programs were all that most health experts could think of through most of the 1970s. And most ordinary Americans at that time saw smoking as just another unfortunate individual "lifestyle choice" - unhealthy but a matter of personal preference. In that decade, though, small groups of activists outside of medicine and public health introduced a fringe idea: people smoked not because of personal choice, but because of the massive promotion by the tobacco industry and a supportive social environment the industry created. The responsibility for smoking lay not with individual smokers but with the tobacco industry and the everyday world they created. The victims of the industry were not just the smokers but also non-smokers forced to breathe their sidestream smoke. The activists thought the only way to cut smoking rates was by making smoking socially unacceptable, and that meant changing the everyday world.

In the beginning, the activists only asked for something that sounds pretty tame - separate smoking and non-smoking areas in workplaces and restaurants. Because these clean indoor air laws protected nonsmokers, average citizens supported them, and initially city and town councils approved them readily. It didn't take long for the industry to realize that these laws had real power - power that education didn't. Because they lifted smoking out of the category of personal behavior and relabeled it as an act dangerous to others, they held the potential of changing the social norm. An internal report by a polling organization prepared for the Tobacco Institute in 1978 called indoor smoking restrictions "the most dangerous development to the viability of the tobacco industry that has yet occurred."

For all of these arguments that we hear against creating more rules and regulations to change our world to make ourselves healthier, Americans as a group actually like the idea. The hottest, most exclusive and most expensive neighborhoods these days are gated communities, which are so heavily regulated that people can't even choose what color to paint their own houses. Even beyond subdivision rules, when it comes to things that harm them, citizens generally want more regulation. Majorities of Americans favor complete bans on drinking on streets, in parks, on beaches, and on college campuses, and by roughly 2:1 margins, citizens support bans on alcohol billboards and television ads . In national polls, a majority of Americans want the federal government to do more to regulate violence on television, 77% of Americans think violence in movies is "very" or "somewhat" responsible for the violence among teens and 64% think we need stronger laws to protect teens from violent and sexually explicit images .

Increasingly, Americans are also seeing obesity as a public problem that the government needs to help solve. Nearly 60% of Americans want to ban junk food vending machines in schools . Roughly the same percent want to restrict ads of junk food aimed at kids on TV . To fight obesity, 81% of Americans think we should create more public spaces for people to exercise and 77% support government-funded campaigns promoting eating right and exercising .

And in this society that supposedly hates government, citizens even have a soft spot for taxes on products that hurt us, as long as the money goes to something worthwhile. In virtually every state that has polled on this, including tobacco-growing states like Virginia, large majorities of citizens favor higher cigarette taxes . The support generally varies with how the tax revenues are to be used, but healthy majorities support these taxes even if the money is only used to help balance state budgets . In a national poll commissioned by the Robert Wood Johnson foundation, 82% of Americans favored an increase in the tax on alcohol to pay for programs to prevent teen drinking, and 70% supported an increase in alcohol taxes just to lower other taxes . Even if the money were used "for any government purpose", which to most Americans sounds like throwing it away, 37% of Americans want higher alcohol taxes . And for all that it is ridiculed, 41% of Americans support a tax on junk food, even when the tax money is not specified to prevent obesity .