by Jonathan Heller
The dominant narrative in the United States is that, as individuals, we hold the key to our own success. We are told to pull ourselves up by our bootstraps and that if we just try hard enough, we’ll succeed.
In the world of health, this translates into a focus on personal behaviors: eat well, get exercise, don’t smoke, and you’ll be healthy. The health care system becomes the solution to health problems: if we are sick, a doctor can fix our individual problem. There are, of course, exceptions to this way of thinking. But, by and large, this is our narrative of health.
We in the health field need to challenge this dominant narrative with an alternative understanding – that our health is created collectively and that collective efforts are necessary to improve our health and well being. Until the emphasis on individual-level change shifts, we will make very little headway to improve health and reduce inequities for the millions and millions of people suffering throughout this country.
Let me back up and make my (oversimplified) case.
I just got back from a vacation in Amsterdam where I saw how different things can be. I did not see a single homeless person. The area of the city we stayed in, we were told by planners, “only” had a 30% set aside for “social” (i.e., affordable) housing, much less than other parts of the city. We did a lot of biking and much of the bike infrastructure was the result of investments in the last 20 years. There was a narrative that emphasized the need for collective action and collective responsibility. By some accounts, this stemmed from the historical need in the Netherlands to build the canals and dikes to protect the country from flooding.
This understanding of the need for collective action is not some radical left wing agenda. Their current government is right of center. People there greatly value individual rights (e.g., allowing drug use) and have a strong history of religious tolerance. And market capitalism actually originated in Amsterdam (as a way to distribute risk collectively, among shareholders).
Returning from Amsterdam, it seems that our individualistic worldview in the US really hurts us. There are often massive fights to build far less affordable housing than we saw in Amsterdam because it’s viewed as infringing on profits and social engineering. Cities are still struggling to build bike infrastructure because it’s viewed as infringing on the primacy of the car. But, more deeply than these policy differences, our individualistic worldview leads us to believe that we get what we deserve and it inhibits our sense of shared responsibility and collective action. This attitude leads us to ask questions like: why should we pay taxes for those who aren’t working hard enough? It also allows us to justify inequality.
A few – mainly corporations and their disproportionately wealthy leadership – benefit economically by promoting this narrative. But it harms the rest of us. It has led to a distrust of government and its potential for collective action; to disinvestment, especially in communities of color; to competition among groups (e.g., low-income whites, recent immigrants, African-Americans) who are pitted against one another for seemingly scarce resources; and to an anti-regulatory environment.
Our collective choices that stem from this narrative have harmed health in countless ways. To give just a few examples: The belief in free-markets and competition has driven down wages and work stability, which are among the most important determinants of health. An anti-regulatory climate around resource extraction and freight transport has resulted in water, air, and soil pollution in low-income communities and communities of color. Public schools experience disinvestment while we turn to the private sector to fix our schools – despite the lack of evidence that these schools do any better. We have a weak social safety net that allows people to go without healthcare, food, housing, and transportation, all to the detriment of health.
Think about what our national narrative used to be in the not too distant past. For example, President Kennedy said in 1961, “Ask not what your country can do for you – ask what you can do for your country.” If our narrative shifted back to an understanding that “we’re all in this together” and that collective action is necessary, the impact for health and wellbeing would be tremendous. Higher incomes, better environments, better education, a strong social safety net, and better planned communities.
I saw what a different narrative could do while I was in Amsterdam (the birthplace of corporate capitalism, no less). The Netherlands is doing better than the US on most health statistics – life expectancy, infant mortality, malnutrition, obesity rates, respiratory disease rates, heart disease deaths, birth outcomes, suicide rates, motor vehicle deaths, and the list goes on. While the health community alone can’t change the dominant narrative in the US, we can lead the way. Let’s find our own collective voice and speak up! The health impacts would be amazing.
Jonathan Heller is co-director of Human Impact Partners, an Oakland, Calif., nonprofit that conducts community-based studies of the health and equity impacts of public policy.