For decades, researchers have worried about disappointing (and now negative) gains in American population health. The pages of Health Affairs are filled with these discussions. Kindig & Mullahy ask whether the “fantasy equation” can be solved and how, i.e., what is the optimal balance of investments in the determinants of average health and health equity? Besides a brief reference to gun violence and our inability to fully engage it as a matter of public-health research and policy “because of political restrictions,” the concept of culture does not appear. Yet culture matters deeply. It informs the way in which problems are perceived and limits our actions.
Our culture—in all its complexity and bi-directional causality—prevents meaningful progress on the fantasy equation, literally stopping us dead in our tracks. Although our American culture—which like all cultures is a tool with many applications—was integral to meeting past challenges, it is poorly adapted to health problems in the 21st Century. The legendary (if not mythical) strengths stimulating the evolution of the US into a superpower in the 19th and 20th centuries—rugged individualism, independence, militarism, skepticism of centralized government, and innovation at nearly any cost—serve us poorly as we endeavor to be healthy in the 21st century.
Below, we delve more deeply into how our culture stands in the way of progress on public health. We also discuss two complementary ways to discuss this problem: First, by framing public health measures in ways that accord with American cultural values, and second, by working to change culture when necessary.
Concern about cultural issues is longstanding. The National Academies of Science, Engineering and Medicine produced two superb, now dated, studies: For the Public’s Health: Investing in a Healthier Future (2012), and US Health in International Perspective: Shorter Lives, Poorer Health (2013). The first report contains a terse observation:
“… to the detriment of society, its fixation on clinical care and its delivery eclipses attention to population-based activities that offer efficient and effective approaches to improving the nation’s health.”
The second report teases a unifying theme:
“Given the pervasive nature of the low US rankings—on measures of health, access to care, individual behaviors, child poverty, and social mobility—the panel considered the possibility that a common thread might link the multiple domains of the US health disadvantage. Might certain aspects of life in modern America—including some of the choices that American society is making (knowingly or not)—be part of the explanation for the US health disadvantage?”
This report also includes a blunt summary:
“Ultimately, meaningful initiatives to address the underlying causes of the US health disadvantage may have to address the distribution of resources that are now directed to other categorical priorities—a change that is likely to engender political resistance. Is a shift in priorities warranted? This report documents that the United States is not keeping pace with other high-income countries in many areas of health and socioeconomic well-being, and the consequences to the nation can be measured not only in lives, but also in dollars. Understanding why this is occurring and identifying policies that could reverse these unfavorable trends are clearly important for the nation’s future.”
While these reports implicitly reference American culture, progress depends on being careful and explicit about the meaning of “culture”—along with its implicit synonyms like “choices that American society is making,” “political resistance,” “fixation on clinical care,” and so forth.
What Do We Mean By Culture?
Defining culture is complex and controversial. There is a long list of values that underlie cultural beliefs, e.g., views on wealth, power, equity, overlapping rights, and the limits on democratic processes embedded in the filibuster and electoral college. Fortuitously, the US State Department has identified eleven cultural attributes that are specific to America in the extent they appear in this country:
- equality (rather than equity);
- informality; and
- efficient use of time.
To avoid being hopelessly bogged down debating which values most represent American culture, we take these as an adequately rigorous starting point for an overdue discussion of American culture and how it influences policy, research, public health practice, and outcomes.
This list highlights the problem of the way American culture circumscribes population health. There is no mention of community, solidarity, the social fabric, or the common good. In short, American culture is heavy on me and light on we—in other words, light on the attributes that are critical to public and population health and wellbeing.
American culture clearly contrasts with culture in other western nations. Most of our peer nations specifically grant positive rights to the individual—to adequate shelter and food, a living wage, and access to health care. Such rights are not primarily individual rights but obligated to individuals as members of society. Denmark is widely seen as a leader in granting these positive rights, yet they were not developed there out of a liberal sense of compassion. Instead, it was a deliberate project of the late 19th Century, a means of linking individual Danes into a uniquely Danish identity. This development was not a progressive project, but a collective one. Similar developments occurred in other industrialized countries, to create social solidarity in the run-up or aftermath of war, or as part of a deliberate political philosophy.
It is particularly striking to note how poorly nationalism substitutes for social solidarity. A belief—meaningless if subjective and misguided if objective—that the US is the best country to live in, actively inhibits efforts to improve the conditions in which people can thrive.
We turn to examples of American culture that lead to poor health outcomes and connect each failing to the above list.
American Exceptionalism: 10 Instances Where Our Culture Puts Us Last In Our Class
We list ten outcomes with devastating consequences that arise directly from the 11 cultural dispositions described by the US State Department. We add two attributes: lack of social fabric, solidarity, or the concept of the long-term common good; and a puritanical legacy. Our list is neither comprehensive nor mutually exclusive.
- Chronic underinvestment in public health, and—ironically in the country with Silicon Valley—underinvestment in data infrastructure including “equity-centered” public health data. This underinvestment stems from excessive weight on individuals, independence, consumerism, and perhaps informality (##1, 3, 9, & 10). This highlights our societal emphasis on treatment over prevention and the under-appreciation of chronic conditions as a health challenge.
- Specialist supremacy over prevention and primary care. At the extreme, specialists may look down at their primary care colleagues. Primary care careers are relatively poorly compensated (important given medical school debt) and not considered prestigious. International surveys routinely show gaps between the US and peer countries on primary care quality. We perceive excessive weight on independence, individualism, meritocracy, innovation, and efficient use of time (##1, 3, 6, 8, &11). The emphasis on equality (#2) instead of equity contributes to a health care system in which some have exorbitant, gold-plated health care, incentivizing waste, while others have none. To paraphrase Anatole France, American culture, in all its majestic equality, offers the rich and poor alike the opportunity to pay for concierge care.
- Fascination with silver-bullet treatment (related to 2). Why struggle promoting health when treatments lie around the corner? Self-described “miracle” cures have a long history in the US. The definition of marketing as protected commercial speech—not the case in other countries which restrict advertising of medical services and products—has exacerbated an American tendency to be independent of government control and science. “Policy resistance”—i.e., behavioral changes that reduce gains from health initiatives, such as more smoking (drinking) following the introduction of low-tar cigarettes (light beer)—is reinforced via TV, as the US is one of only two developed countries allowing direct-to-consumer advertising of pharmaceuticals. Problems: excessive weight on independence, nationalism, innovation, consumerism, and efficient use of time (##1, 5, 8, 9, & 11), and inadequate attention to the long-term common good.
- Punitive/criminal response to addiction and serious mental illness rather than prioritizing treatment, but also a bureaucracy that is distrusted and ineffective. Problems: excessive weight on individualism and meritocracy (##3 & 6), plus our puritanical legacy.
- Parsimonious treatment of the poor and disadvantaged, bordering on blame-the-victim policies. A compelling example is work requirements for Medicaid eligibility. Twelve states still resist Medicaid expansion despite federal policy that more than funds its costs. Essential programs such as SNAP benefits are under continual threat, while other key programs suffer delayed reauthorization. The legacy of structural racism is an ongoing stain, with well-documented costs of racism and resistance to reparations. Problems: excessive emphasis on independence, individualism, and meritocracy (##1, 3, & 6), and a short-sighted substitution of equality (#2) for equity and solidarity.
- Anti-Science. The Covid-19 pandemic has shone a powerful spotlight on the ways in which much of the US population is anti-science. Other countries have anti-science minorities, but few experience widespread antipathy to science, and rarely has such antipathy become a shibboleth of one of the major political parties (though as evidenced by the conspiracy theories about vaccines that circulate among some liberals, anti-science attitudes cross party and ideological lines). Anti-science attitudes have included fights over mask wearing and vaccination mandates, an inability to properly grieve and celebrate the million lives lost, ACA legislative language prohibiting the use of science to reduce ineffective medical treatment through the use of cost-effectiveness analysis, and distrust in institutions and one another. Problems: excessive weight on independence, individualism, nationalism, and consumerism (##1, 3, 5, & 9), and insufficient emphasis on solidarity, and health.
- Tolerance if not encouragement via tax and spending policies, of extreme income and wealth inequality, creating fissures in social cohesion. Citizens United helped clear the way for disparities in wealth to translate into disparities in political power. Internationally low relative tax rates lead to correspondingly weak investments in the social and environmental determinants of health. Indeed, there is an entire industry devoted to misinforming Americans about purported “confiscatory” taxes and “wasteful” social spending, e.g., that “death taxes” will ‘steal the family farm, even though in 2022 the estate must be valued at over $24 million (married couple) before estate taxes apply. Consider also the constant rhetoric that income and wealth mobility remain robust despite overwhelming contrary evidence, Problems: emphasis on independence, individualism, and consumerism (##1, 3, & 9), substitution of nominal equality (#2) for equity, an understanding of democracy that is historically skeptical of conferring power to people (#4), pernicious reading of meritocracy (#6), and failure of solidarity and the long-term common good.
- Obsession with elite athletes yet minimal commitment to fitness and health instruction. The athletically gifted get scholarships while the uncoordinated poor get obesity. There’s a destructive emphasis on discovering athletic talent at young ages, creating stigma for the less physically skilled. Poor instruction in physical education and a failure to view healthy activities and diet as life-long pursuits are the norm. Problems: excessive weight on individualism, meritocracy, and consumerism (##3, 5, & 9).
- Failure to seriously address long-term cataclysmic threats to population health such as global warming, drought, and overpopulation. Whether at the scale of the globe or the neighborhood, Americans are notoriously slow to adopt necessary policy solutions to solve collective-action problems. Climate change is an obvious example. On a local but significant scale, NIMBY-ism prevents the production of adequate housing, creating imbalances in supply and demand that have resulted in high housing costs and worsening homelessness. Both situations are deleterious to population health. Problems: excessive weight on individualism (#3), and insufficient attention to long-term common good, equity, and solidarity.
- Despite important new legislation, the US has ubiquitous gun possession with few controls. This is a direct result of past policy positions arising out of an ethos of independence (#1) and individualism (#3) that has been channeled by the industry into a vision of self-defense focused on unfettered personal gun ownership. America has seen 12.6 million life-years lost to gun violence in the past decade and 45,000 gun deaths in 2020 alone, the majority of which were suicides. We are unable to ban assault weapons and high-capacity magazines, or raise purchase age; the day before the new legislation passed, the Supreme Court ruled that state efforts to restrict guns in public are unconstitutional. Since these gun safety provisions are popular, there is also a failure of democracy (#4).
Can Cultural Lemons Be Squeezed Into Population Health Lemonade?
As we bowl alone in greater numbers and belong to fewer organizations, we have lost the strength of community. Even before the pandemic there was a growing epidemic of loneliness. Jonathan Haidt claims, “We are disoriented, unable to speak the same language or recognize the same truth. We are cut off from one another and from the past.” There could hardly be a stronger indictment of the undue weight American culture places on independence, individualism, meritocracy, and consumerism. Derek Thompson calls it a death trap and advocates for an abundance agenda.
Rather than accepting paralysis because changing culture is too difficult, let’s celebrate victories, e.g., smoking cessation, less driving and drinking, greater seat-belt usage, roadway rumble strips, and safety initiatives introduced into myriad youth sports and outdoor activities. Culture does change. Public health can be improved in various ways, including federal regulatory changes, and in states where it might be least expected.
While there are countervailing forces such as social media that foster extremism and breed disunity, there are positive ways to generate cultural shifts, including technological developments such as good-tasting, affordable, and healthier plant-based meat, or research on effective communication techniques to coax individuals into understanding the determinants of population health. There are innovative initiatives to boost upstream investments in drivers of health and novel efforts to create healthy/ wellness villages.
Rebranding Public Health To Change Perceptions
Public health interventions work in many ways, constraining some, e.g., food marketers, polluters, insurers, and providers, and protecting others, e.g., children, communities, patients. Thus, health policies can be represented as constraints or protections. Because people naturally avoid danger, when protections are afforded, more activities are open to people. Protections lead to greater freedom and public health should work to ensure they are perceived as such. Working with the grain of American culture means emphasizing protections and freedoms; current practice emphasizing restrictions and individual behavior change works against the grain and is less successful.
Research in cognitive linguistics shows that how a proposition is presented matters immensely to how it is received, and almost everything can be presented through multiple frames. A speed limit is a restraint on car drivers, but it is also freedom for parents whose children play on the neighboring sidewalks. Research is applying these insights to public health.
Introducing the phrase “upstream determinants of health” in 1975, John McKinlay warned of the exploitive power of the sugar industry, which he framed as a manufacturer of illness. The medical care system has co-opted the term health care, framing public health as subservient to individual clinical care rather than recognizing it as one of many components of population health. Notwithstanding this powerful original framing, public health has defaulted in its battle against obesity to a frame of individual responsibility. This is a self-inflicted wound, a dangerous mistake on behalf of the field. A study of framing messages around obesity policy showed that including a couple of sentences about the efforts of food marketers to increase demand for their products, through advertising and sugary and salty additives, leads to a nearly 40 percent increase in support for public health policies to increase healthy food availability and limit advertising to children. In effect, this messaging strategy leveraged American values of individualism and consumerism against the attempts at manipulation by the food industry while still acknowledging McKinlay’s original insight. This is an example of working with the grain of American culture rather than against it. Similarly, identifying soda companies as the source of opposition to taxes on sugar-sweetened beverages significantly increased public support for taxes.
Of course, unsuitable framing can turn people off. Opioid abuse disorder is typically framed in the media as a crime and an individual failure rather than a treatable public health problem. It is the rare news story that mentions substance abuse treatment as a solution. Public health must work aggressively to change framing in the popular media as an extension of its core function of educating and empowering the public. Clearly, we have much work to do.
Research is vital. A major Robert Wood Johnson Foundation (RWJF) study found that while most Americans embraced the values for the conditions underlying health, using phrases like “social determinants of health” was a near-universal turn-off. Conservatives disliked terms such as “barriers” to health but were more open to understanding health as evolving along a pathway. There is much productive research to be done to support the educational mission of public health in ways that work within the American cultural context.
American Values And Public Health
Those who are skeptical of the motives of the public health enterprise describe it as attempting to create a nanny state in which individual freedom is not only constrained, but further infringed on, by a badgering to eat healthy, exercise frequently, get cancer screenings, and subsume a variety of pleasures to the sole end of prolonging life. While health is important, it is not the only value for Americans, or even a prominent one. Public health needs stronger, clearer branding emphasizing both the common good as well as the value to individuals and clever incentives (a savvy state). We now take for granted the listing of calories per item at restaurants.
For example, laws mandating bike-helmet use seem like straightforward public-health interventions to reduce head injuries among cyclists. Yet such laws discourage biking and have no net effect on head injuries. Countries with the most robust infrastructure have the highest rates of biking, low helmet use, and yet the lowest rates of injuries. Instead of focusing on mandatory helmet laws, the best way—the only way—to reduce biking injuries is to focus on systemic change. Messaging around the importance of structural over individual behavior change should be emphasized not only for external audiences but for those within public health itself.
Telling The Right Stories
Public health is overwhelmingly framed in terms that are inward-focused and likely to be off-putting or unhelpful to the public. A Google search of “public health success stories” turns up websites extolling process measures: focus groups that went well; individuals successfully connected to services; and interventions that increased awareness of preventive health measures. One study describing public health success stories notes that “in the last third of the century, tobacco consumption decreased by more than 50 percent, and rates of heart disease and stroke deaths, and later cancer deaths, declined similarly.” Yes, this is a success story for public health, but it is manifestly not a success story of public health for the population.
A story should have characters with desires and an evolution toward them, typically in the face of opposition. The history of public health is full of such stories: victory over the tobacco industry and its web of lies; compelling car manufacturers to improve safety; and ensuring a safe supply of food and water against the implacable opposition of libertarians. The key element for effective storytelling is recognizing that the protagonist is not public health, but rather the community, the American people, “the little guy.” Public health is simply the name we give to many little guys and gals who join to expand their own freedoms in ways that improve the conditions in which people can be healthy. Such grass roots efforts subsequently motivate legislators, lawyers, and investors to act, e.g., on tobacco litigation, ESG investing, and climate policy. This is a story that must be told, and it is existentially urgent that public health tell it. Storytelling is not fluff—it is amenable to hard-headed research and is essential to our practice mission.
Understanding the importance of American culture as a driver of health means that public health messaging must better communicate and prioritize structural changes that transcend individual behavior. This work is extremely important and deserves more exposure and support, not only because it is evidence-based, but also because it is truer to the historical mission of public health to further “society’s interest in assuring conditions in which people can be healthy.” This mission is patently not about the individual, but about society—the collection of individuals whose health prospects generally rise or fall together. We advocate for funding and research dedicated to fulfilling the promise of this mission.
Changing American Culture
Changing American culture to incorporate values of social solidarity is an enormous mandate that must overcome centuries of embedded racism, class antagonism, and a myth of lawless individualism. Yet, difficult is not impossible. The political scientist Fred Frey observed a classic move of the powerful: “Why let things be merely difficult when, with just a little more effort, we can make them seem impossible?” After all, culture does change, often via deliberate efforts. Several approaches for moving culture in a direction more amenable to public health have been suggested, attempted, and even borne fruit.
Cultural Change And The Public Health Perspective
We noted that bike-helmet laws can be counter-productive. The explanation illustrates the contributions that public health has to offer for a more inclusive American culture that values community—as an additional, not exclusive value. For an individual, wearing a bike helmet is clearly protective. Yet mandating helmet laws doesn’t reduce injuries or fatalities. How can both be true? Because what is true at the individual level is not necessarily true at the societal level. When people are discouraged from biking, there are fewer bikers. With fewer bikers, car drivers do not expect to encounter them, and each biker is in greater danger, i.e., less safety in smaller numbers.
The effect of exposure for any outcome is affected by the context in which it happens, and this context is deeply affected by what other people are doing. This phenomenon has been frequently observed going back to Virchow, and is reflected in Jane Jacobs’ concept of “eyes on the street” for public safety, the ability of individuals to access medical care in their own language, and in the robustness of insurance markets. Public health is well-positioned to drive this insight deeply into the culture so that we recognize as a shared value that we are all affected by the actions of others.
Cultural Change Starts With Science
Methodological individualism is the primary scientific paradigm in empirical public health—and it is deeply flawed. It assumes that any observed change at the individual level that results from an exposure is an accurate analog for the change one expects at the community level for the same exposure. For much of public health, this assumption is not true. In Nicaragua, parents of vulnerable children were offered conditional cash transfers to keep their oldest daughters in school. A randomized-control trial showed that the program worked. However, a different study team found that in times of income stress, families reallocated resources away from younger children to keep the oldest child in school and maintain access to the cash. “In other words,” according to study authors, “the negative effects of being hit by the shock were amplified by being in a treatment community.”
This crucial insight was missed in the original analysis because of a fatal flaw of methodological individualism, not an execution error. The experiences of treated vs. control individuals are not generally an accurate guide to the effects of a policy in a population. Yet, methodological individualism lumbers on, like a zombie idea refusing to die. Science, too, is part of American culture, and must evolve.
Public health can engender a change in American culture by changing its own scientific culture. We must be evidence-based, but we must also recognize that evidence can come from fields such as sociology, anthropology, political science, and cognitive science. Not all evidence comes from randomization. Randomized trials work well for discrete interventions whose outcomes are limited to the subjects involved (typically clinical trials), but less well for interventions that also have consequences to others. One of the challenges for establishing a sound evidence base for population-based interventions is the lack of a systematic and accepted framework for integrating information from the fields noted above. While there will always be an important place for experiments and randomized-control trials, these cannot be the sole or even primary guide to the scientific approach to fostering cultural change.
Research On Cultural Change
Important research is underway already. The same RWJF study that showed that the phrase “social determinants of health” was off-putting also found that reminding people that “health starts in our homes, schools and communities” was effective in reaching them. This is a subtle but important difference, and it suggests that cultural change—in which people assemble to accomplish meaningful improvements in and for their communities—is possible. Apt messaging is vital for cultural change. In contemplating a public health “awakening,” Dave Chokshi mentions the need for new narratives, e.g., moving away from zero-sum thinking. New research from Raj Chetty and colleagues illuminates strong links between economic mobility and social networks, i.e., “friends.” Social capital matters and public health can play a large role.
Public Health As Convenors For Cultural Change
Public health has other historical advantages beyond messaging. Its practitioners are natural conveners, bringing together community activists, advocates, and organizers to accentuate the common good of the community. Such efforts are common in public health practice but deserve more funding support and scientific and political legitimacy.
Necessary cultural change will support and often require policy change. Over the latter half of the Twentieth Century, unions were decimated by a deliberate strategy that united the self-interests of the wealthy with a neo-liberal ideology. This did not arise organically; it was deliberately engineered through a dense network of right-wing think tanks funded by corporations and über-rich donors.
To whatever extent this right-wing network believed in the virtue of their work, they certainly didn’t assume that this goodness was sufficient to create culture change. On the contrary, they invested heavily over a long period to engender both the policy changes and cultural evolution that they desired. The right-wing didn’t create American culture, but it put its fist on the scale in favor of individualism, consumerism, and a pretense of meritocracy, against a backdrop of highly unequal opportunity, nationalism, and a focus on efficiency above common good. This cultural bias is also observed in the financial community’s inexorable focus on the “next quarter” with scant regard for the social good or even the long-term corporate good. The State Department characterization reads like a right-wing wish list, and not by accident. One of the leaders of this neo-liberal movement, Margaret Thatcher, succinctly said, “There’s no such thing as society.”
Public health must meet the need for cultural change with an equal, but opposite, vigor. It should involve new research that departs from recent public health concerns of cancer screening, toxic exposure, and pandemic preparedness to a focus on how Americans do come together, when they do, and why. We urge the field to research trust in neighbors, social isolation, the facilitators, and barriers to participation in community activities, and a sense of belonging. It’s not the job of public health to accomplish these goals. Rather, public health and others in and outside the health arena can play a role in convening, monitoring progress, motivating others on the health impacts of success, and so on. Without a rebalancing of American values to include common purpose and public welfare, public health—and its mission explicitly including “society’s interest”—will be lost.
To transition from our me-centered history to a we-centered culture will require multiple changes. Discussing the “Island Where People Forget to Die,” Dan Buettner writes, “The big aha for me, having studied populations of the long-lived for nearly a decade, is how the factors that encourage longevity reinforce one another over the long term. For people to adopt a healthful lifestyle, I have become convinced, they need to live in an ecosystem, so to speak, that makes it possible. As soon as you take culture, belonging, purpose or religion out of the picture, the foundation for long healthy lives collapses.”
How will the American cultural landscape look in 15 – 20 years? We believe in a transformed culture that moves from ‘it’s all about me’ to one that celebrates the us in the US. While each of America’s cultural attributes is virtuous, the imbalance of those attributes has led to self-destructive policies. Rebalancing our portfolio of shared cultural values can vastly improve our policy options. Public health work to improve American culture can inspire the conditions in which people can be healthy by creating an ecosystem that does not stop us dead in our tracks but stimulates thriving lives.
We gratefully acknowledge suggestions on initial drafts from David Kindig and Sanne Magnan, and comments from Dave Chokshi, Jonathan Gruber, and Scott Keller. We bear complete responsibility for the final product.