The conditions of where we live, work, and play, our wealth and resources, inexorably shape our health. But how do these social forces become health? Through a variety of mechanisms, one of which is, unquestionably, our behavior.
If I am living in a dangerous unwalkable neighborhood I am less likely to exercise, and more likely to suffer from obesity and attendant heart disease. So, behavior is integrally linked to the world around us, but also itself central to our efforts to improve the health of populations.
This has never been clearer than during Covid-19. Differential early burden of Covid-19 was driven in no small part by changes in behavior. As those with resources were able to shift rapidly to working from home, they had lower risk of acquiring Covid-19, and subsequent lower burden of infection and death from the pandemic. Yet as Covid-19 progressed, prolonged social isolation became associated with harmful behaviors including use of substances, leading to a surge of poor health we will be dealing with long after the worst days of Covid-19 have passed.
That we have not been able to mitigate some of health risk behaviors during Covid-19 highlights a fundamental problem we have with health behaviors: we know both that they are influenced by the world around us, and that they are hard to change. While public health is built on success stories such as reducing population smoking or improving seat belt wearing, these changes took decades, further emphasizing how hard it is to effectively change behaviors that lead to better health. And while we often imagine that having adequate risk information at hand will lead us to make different behavioral choices, studies repeatedly have shown this not to be the case.
What might we learn from the Covid-19 moment that can nudge us as a country to better health going forward? Two simple points emerge for us.
First, recognizing that context shapes health behaviors, it is imperative that we bear this in mind whenever context is changing. It is not a surprise that large scale staying at home, and the social isolation that goes with that, is associated with greater substance misuse, and attendant drug overdose, for example. This needs to be part of our calculus when we are creating policies to, for example, change context to reduce the spread of a new infectious disease.
Second, health behaviors are often driven by broad social phenomena. It is likely, for example, that the move to staying indoors had as much to do with fear of Covid-19 as it did with any specific stay-at-home orders. This suggests that the tools for changing behavior have to extend well beyond the individual, and fundamentally tackle our cultural norms, bringing us back to context.
These observations do not particularly solve our problem with health behaviors. They remain difficult to change and will always be so. But they do perhaps sharpen our thinking about the importance of anticipating, and valuing, a range of behavior changes when context changes, and engage us with asking, always, how can we change context in such a way that it promotes healthy behavior?
Michael Stein & Sandro Galea
As we re-emerge from the pandemic, 2021 stands to be a turning point year for public health. In The Turning Point’s weekly essays, we reflect on what we learned during 2020, and what we are learning during 2021, that can guide us to the creation of a better, healthier world.