Laura is a 42-year-old woman who comes to see her primary physician. She is about 40 pounds overweight and has progressively worsening and painful osteoarthritis in her left knee. She has asthma, which keeps her out of work at least one day a month.
This is not an unusual presentation to any primary physician’s office. Her physician will look after Laura, prescribing inhaled steroids for her asthma, recommending weight loss through better diet and exercise, and prescribing anti-inflammatories for her painful arthritis until she gets to a point where she needs more or different medications, and later a knee replacement.
And there is nothing wrong with treating Laura in this way: it is in fact good care by a responsible clinician. But why is Laura, at 42, overweight, and why has she long had asthma attacks?
She is overweight because as a child of a single mother who had to work multiple jobs to keep the family afloat, Laura grew up eating unhealthy but affordable food. This led to her becoming overweight at a young age, making it much harder to take off pounds in adulthood. Her knee arthritis is directly a result of her weight, but compounded by her job working in an office, where she sits all day, with relatively few breaks. And her asthma got worse as a child when, in the lower income neighborhood where she grew up, a bus depot was sited, spewing diesel fumes that inflamed her airways.
So, Laura the patient needs treatment today, at 42. But her medical conditions are a product of her past and of the world in which she grew up. Her physician can say to Laura that she should eat better and exercise more to lose weight, but what chance does Laura have if her asthma makes even exercise challenging and the cost of healthy food is prohibitive?
We suspect that most readers will recognize that Laura was not well served by life’s lottery. Perhaps some of us were luckier than Laura in our circumstances of birth; others may not have been. Critically though, it is true for all of us that our health today is a product of our past.
If we were to choose one thing to do to maximize our health, we would do well to choose to be born to high-income, well-educated parents who live in good neighborhoods.
The public’s health is inextricable from our past, our place, our politics, and the powers that shape these factors. We can keep treating Laura, and keep spending more and more money on healthcare, but until we invest in a world that produces, promotes, and supports health, we are always playing catch-up and we can do much better than that.
Warmly,
Michael Stein & Sandro Galea