Thank you to everyone who posted comments on the discussion board. You’ve brought up some good points about the challenges of improving access to healthy foods. As someone who has been known to regard “one row of marshmallow peeps” as a nutritious breakfast, I am not sure I am the best person to moderate this discussion, but I will give it a go.
A Brief History of Epi-What?
The history of epidemiology (not to be confused with the study of human skin, which is what a kid in one of my biology classes thought he had signed up for) lends insight into why so few doctors go beyond treating disease to ask why certain patients get sick in the first place.
In many ways, medicine and public health have gone their separate ways. People today tend to focus on the link between exposure and disease in individuals (“I ate peeps for breakfast for two months and now I have a vitamin deficiency”) rather than the factors that influence exposure in populations (“everyone around here eats peeps because one row is cheap and filling”).
But this wasn't always the case: The early 1800s was a time when the medical community put great effort into understanding the social and environmental causes of illness — like crowding 30 people into a brownstone with no plumbing. By the end of that century, their attention turned to "germ theory," or the role that bacteria and viruses play in making us sick. Since World War II, the focus has been on chronic conditions such as diabetes, which today impact far more people in the industrialized world than infectious disease.
In my opinion, the progressive de-emphasis on social and environmental context has been harmful, given the known correlation between health and factors such as income and neighborhood environment. That is why Bostonians like Dr. Nancy Krieger have been outspoken about the need for citizens, elected officials and health care providers alike to ask “who and what is responsible for population patterns of health, disease, and well-being, as manifested [in] social inequalities in health."
The Cost of Healthy Choices
Let's face it: Everyone knows that poor diet and lack of exercise are bad, bad things. Nevertheless, two-thirds of all people in our country are overweight, and of them, more than half are clinically obese. It's pretty obvious that knowledge hasn't curbed our addiction to fast food, so in the words of Bruno: What's up?
While it's hard to deny that what we eat is largely a function of individual determinism, for many people in cities and rural areas, it is also a function of neighborhood environment. A recent study, for example, found that the presence of supermarkets where fresh produce can be bought at fair market prices is correlated with a person's likelihood of eating well. Put simply, living in neighborhoods where the only choices are convenience stores and high-priced specialty markets makes purchasing produce cost-prohibitive.
My neighbors are primarily working-class people who don't own cars, meaning they rely on public transportation to get to the supermarket. It's no wonder that at the end of a long work day, many settle for the affordable fast-food alternative. Is price the only reason fruits and veggies get the boot? Probably not, for the same reason I continue to eat peeps even after viewing these experiments. The bottom line is that if there is a lack of affordable healthy food choices in a community, a person's decision to eat better is less likely to come to fruition. So where do we go from here?
Putting "Real Food" Back on the Table
Last week I paid a visit to the Bowdoin Street Health Center in Dorchester, whose providers play an active role in promoting community health by partnering with local businesses and even employing community organizers. What I saw when I pulled into the parking lot was this sign, which I think speaks to Steve's question about whether farmers' markets are catering to middle- and high-income people.
What I found out is that there is a growing movement to promote availability of whole foods that don't cost a "whole paycheck." As Katie commented, both grassroots campaigns and government initiatives are helping Americans to put "real food" back on the table.
In Boston, farmers' markets are being set up in even the most unlikely locations — from inner-city clinics to highway rest stops. And because farm stands are accepting EBT cards and WIC, the produce is accessible to people at all income levels. What makes these efforts unusual is that they are addressing social determinants of illness — as opposed to promoting healthy living without accounting for the extent to which people can control their exposure to risks.
At the federal level, the quest to make healthy food options available in school cafeterias is on the front burner with the Child Nutrition Act now up for reauthorization. As part of a National Day of Action, hundreds of communities are organizing "eat-ins" to support increased federal funding for school lunch programs. In Boston, the Food Project and Boston Localvores are organizing a Labor Day Eat-In in the Common that will take place from Noon to 2:30 pm tomorrow at the gazebo in Boston Common.
A Shout Out to Community Organizers
Yesterday I was at the Norwich Farmer's Market, where I picked up a magazine article by community organizers Angela and Richard Berkfield, who described their successes and failures in promoting access to locally-grown foods in Brattleboro, VT. Their lesson learned was that projects cultivated and led by community members saw the greatest levels of participation. "We need to support projects that come out of communities," they concluded, "instead of doing what we think is needed or wanted."
While only time will tell whether the movement to bring farmers and consumers together has a significant impact on health, the Berkfields' findings say something about the likelihood of success if citizens are not properly engaged.
Have you participated in or helped organize food security projects in your neighborhood? If so, what aspects of these projects have been the most successful? What parts didn't go so well, and why? If you have the chance to post a comment, we here at Real Health Policy would love to hear some of your insights. In the meantime, I am off to Skunk Hollow to enjoy a relaxing Labor Day weekend, Vermont-style...