Second only to the current turmoil in Iran, the state of American healthcare has assumed center stage in our national consciousness…as well it should. Our system is clearly in need of major overhaul. While most European countries spend around 10% of GDP to provide universal health care, we spend 17%, have 16 million citizens uninsured, and are facing escalating costs. These figures are unsustainable. The inefficiencies and failures of our system are multifactorial and will require changes in many different areas. While much of the talk focuses on digitizing medical records, developing a government-backed insurance alternative and creating more efficiency in care, I am particularly interested in the least-discussed cost-saver: the creation of a population that values and practices wellness.
President Obama has promised to bring a new focus on prevention to his health care agenda. It is plainly obvious that preventing diseases before they begin has the potential to be the greatest cost-saver of all. It also gets to the very core of what health care should be: a system that both treats disease and encourages its avoidance. But there is a problem. Americans do not seem to respond to calls for wellness. Lectures, public service messages, exhortations of all types don’t make much of a dent. What do we respond to? Well, we are certainly influenced by the pleasure-seeking messages so carefully crafted by Madison Avenue. Perhaps what we need is a really good ad exec who wants to put together a great wellness campaign.
We certainly talk a lot about getting healthy. We sure have a lot of gyms, fitness facilities, storefront weight loss clinics, yoga tapes, products labeled with little hearts and low fat proclamations. This glut of health equipment and talk reminds me of the old question my father used to ask about our family’s soap consumption. “Boy, we used a lot this month,” he’d say. “Does that mean we’re very clean or very dirty?” Having a world full of fitness equipment doesn’t necessarily mean we’re fit. It more likely means we have a real problem.
This week’s Time magazine is the “Health Issue” and it is subtitled, “It’s All About Prevention.” Here’s how Time introduces the topic.
“One way to cure illness is with pills and procedures. Another is not to get sick in the first place. The great thing about the latter: it’s cheaper, easier, and more likely to save your life.” (italics mine)
Easier? Certainly not in my experience! Changing behaviors and encouraging people to be healthy is nearly impossible. Believe me, after years of working one on one with people, I can tell you that it’s a Sisyphisean task. (You remember Sisyphus. He was the guy who was doomed by the Greek gods to an eternity of pushing a boulder up a mountain, only to have it fall back down once it reached the top.)
Time devotes a good-sized section of its health issue to a new lifestyle program being run by the Cleveland Clinic. In an attempt to motivate change, this program offers intensive education and counseling. Participants take cooking classes, learn exercise and yoga, and get nutritional and stress management training while being personally supervised by many specialty personnel and a program physician. The down side? The program requires a commitment of 8 hours per week for 6 weeks. Currently, the $1500 charge is paid by the individual or by an employer. To its credit, the Cleveland Clinic will pay for its own employees to participate. It is too early to tell what long-term outcomes will be, but the Cleveland Clinic has given its employees a fighting chance at continuing healthy behaviors. Its cafeteria has been purged of bad food choices, it offers free exercise classes to all, it has a farmer’s market on site and it pays for weight loss. It also has ceased hiring anyone who smokes and has become a fully smoke-free campus. Immersion in this type of supportive environment makes permanent behavior change more likely. But most Americans, unfortunately, are immersed in something quite different.
Coincident to Time ’s health issue, the American Journal of Medicine published a study on how well our country is doing with lifestyle behaviors. Brace yourselves. Over the past 18 years, while gyms have sprouted like mushrooms and diet books have broken bookshelves with their weight, Americans have gotten increasingly worse at being well. This study examined just 5 moderate healthy behaviors: eating 5 servings of fruits and veggies per day, exercising at least 3 times per week, maintaining a body weight that is not obese (BMI less than 30), drinking no more than 1 drink per day for women and 2 for men, and not smoking. Since 1988, three of these five behaviors have become less common than they used to be. More of us are obese, fewer of us exercise at minimum levels (43% vs. 53%), and fruit and veggie eaters have plummeted from 42% to 26%. Smoking rates have remained the same. Moderate alcohol consumption is up from 40 to 51%, but there are a number of doctors (myself included) who don’t buy the idea that drinking is the best way to good health. All in all, adherence to all five of these fairly moderate health habits has gone from 15% of the population to just 8%!
Is there any way to turn this tide? I believe it will require a complete reversal on two fronts.
First: our new health care policies will need to support and reward specific healthy behaviors. Currently, for example, our hospital is considering a program that will allow employees to benefit if they can demonstrate certain health markers. These will include not only acceptable levels of blood pressure, cholesterol and so on, but proof that they are exercising, attending educational events, etc. Those who rack up wellness points will receive a variety of rewards, including discounts at local businesses and financial incentives. These types of programs place a value on staying well that is more motivating than the small, internal voice that says, “I know I should change my ways.”
Second: we have to find a way to make wellness cool. This will need to come through an intensive educational campaign that begins in early childhood and is continued throughout the life cyle. All of this will need to be reinforced by prominent role models and by advertising. Like most powerful cultural trends, the “cool” of eating clean, staying lean and being super-fit will probably need to take hold among young people first.
Is it possible that in time we can take a more European attitude toward weight, food and wellness? Will we ever be a more restrained culture? One that is less in pursuit of the immediate gratification of a cheeseburger? One that views real food as the equivalent of fine wine and processed foods as the equivalent of oversweetened cola? If the recent events in Iran have taught us anything, it has been to respect the enormous power of our interconnected, socially-networked world. Ideas and new themes, what some have called “cultural memes,” have the ability to take root almost instantly if the time is right. The question remains, is now the moment for a wellness revolution in America? And if not now, when?