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March 10, 2021+Michael Jindra
+Public Policy

Covid, Health Inequality, and the Avoidance of Behavioral Explanation

This piece is available in audio format on our podcast, “Heterodox Out Loud: the best of the HxA blog.” Narration begins at 1:15.

When it comes to politically fraught social problems, many academics and commentators fail to find the balance needed to adequately understand social problems and come up with effective solutions. To do so well requires good social theory--an understanding of the relationship between human action and the structures and cultures that both fosters and limits such action. The narratives popular in social sciences, however, often produce one-sided theory and approaches. Barbara Ehrenreich’s work, for instance, is popular on college campuses because she tells stories of oppressive structures weighing down noble citizens, but unfortunately criticizes ground- level programs that could actually help them.

The Covid pandemic has brought to light one major social problem: inequality in health. Besides age, underlying conditions such as obesity, diabetes, heart issues and respiratory problems were the key factors distinguishing those who suffered few effects and those who plain suffered, and died. Minorities were hit especially hard, some because of their increased exposure due to service jobs, but even then, those hit hardest often had preexisting health conditions.

These preexisting conditions are rooted in larger, and worsening, health inequalities. Differences in life expectancy by U.S. county have been growing since 1980. By 2014, residents of the highest life expectancy county outlived those in the lowest by 20 years. Counties in central Colorado saw the largest increase in life expectancy, while counties from Oklahoma to West Virginia fared the worst.

Why the variation? A longstanding answer is “structural” factors like the healthcare system, food deserts in inner cities, or the stress of being poor, echoed frequently in places like the pages of the New York Times. Yet multiple studies show that behavioral factors make the difference in health more than socioeconomic, racial, ethnic, or health care system factors. The main driver of the dietary gap, I’d argue, is cultural and interactional, theshared beliefs and practices of peoplearound us. Peers have a strong influence on our eating habits, exercise, and ultimately on chronic diseases like obesity.

Diet researchers have divided people into categories such as “physical fantastic,” “decent doolittle,” or “noninterested nihilist” based on their eating and fitness habits. These categories are not evenly distributed across America but tend to cluster together. The southeastern US has a larger proportion of “noninterested nihilists”—people who eat poorly and do not exercise. Colorado is home to a high number of “physical fantastics” (24% of the population)—people who pay avid attention to diet and fitness.

Behavioral factors are key. Which food and exercise culture you belong to significantly impacts how long you live. In a study in the New England Journal of Medicine, health care only accounts for 10% of premature deaths, genes are 30%, while behavioral patterns like eating, inactivity, and smoking have the most influence at 40%.

Behavioral factors are often class and culturally-patterned. We see this process in the “dietary gap” between the social classes, which has increased over time. Wealthier, higher-status Americans increasingly flock toward farmer’s markets, organic shops, and restaurants promising local, seasonal cuisine. They follow ever-more-elaborate exercise and supplement regimens, and they shun smoking. At the same time, lower-income residents continue to consume fast food and prepared foods at high rates. They exercise less and smoke more.

People don’t share the same conceptions of healthy lifestyle, notions of body size, or taste in food. Some of the highest levels of cardiovascular disease and obesity in the nation are to be found in the so-called “Stroke Belt” of the Deep South and Appalachia, with high rates of obesity, diabetes, and heart disease. Among African Americans, the behavioral patterns of the Southern diet contribute to obesity and diabetes, making African American dietary patterns especially resistant to nutrition interventions. In general, African Americans don’t share the same cultural aspirations toward thinness that whites have and tend to accept larger body sizes (this is true across social classes). Surveys show they eat more for enjoyment than whites, who have more guilt about food, and also more anorexia, which highlights that either extreme presents problems.

The longevity among Asian-Americans (the highest in the United States) appears to be partly related to their cultural practices around diet, which involves low fat intake and high fruit and vegetable consumption. Lower-income groups, such as poor white Appalachians, tend to be more fatalistic about their health, believing that God or other outside forces are in control. This can contribute to less preventative actions, ranging from less attention to diet and exercise, fewer doctor visits (even adjusting for access to health care), or less intense social distancing to prevent disease transmission.

The alleged existence of food deserts in inner cities is another way that scholars have deflected attention away from people’s behavioral preferences. The difference between food availability in high income areas vs low-income areas is 90% due to demand, not supply. The pull of convenient fatty and unhealthy food is simply too strong. Laudable attempts to start farmer’s markets in inner cities end up serving mostly people who are already eating healthy.

None of this denies that systemic racism and other external forces are factors.Discrimination has had an impact on income and wealth inequality. Universal health insurance is a must. But when it comes to health, external forces matter less and culture and behavior matter more.

In other words, behavior at the individual level matters more than structure when it comes to diet and its related health outcomes. This means structural change won’t do much to help people. It doesn’t mean individuals alone are to blame, or that individual willpower will solve the problem.

It means that interventions must target culture: group beliefs, social forces, peer networks.

Public health researchers have been able to follow the spread of obesity in a social network over 32 years, especially among pairs of friends and siblings of the same sex. Their conclusion: people tended to gain weight when their friends and relatives gained weight around them.

In the discussion of Covid, these factors are often avoided by writers in journals and newspapers, who decry “racial capitalism” or “structures” that make low-income populations or minorities more vulnerable. There are strong pressures in writing on social problems to avoid “blaming the victim.” It’s understandable that academics don’t want to unfairly blame people that are struggling. As anthropologist Richard Shweder has noted, however, there is a problem “when victimization becomes the dominant account of suffering and when it becomes politically incorrect to ever hold people responsible for their misery.” This encourages people to think and act as passive victims with few personal capabilities, which certainly does not contribute to their well-being. Shweder argues that people “need to be aware of whatever degree of personal control they have over their own conditions” without going to the extreme of laying all responsibility on individuals. Unfortunately, in sociology and anthropology, structural-only explanations are common. Witness the books that treat the poor entirely as victims such as “Blaming the Poor” or “Disciplining the Poor.”

Similar pressures are at play in Australia, where the ill health and poverty of aborigines have been a contentious national issue for decades. Australian medical anthropologist Emma Kowal has argued that antiracist whites, who understandably lament Australia’s past oppression of aborigines, “overstructuralize” the problem and ignore cultural and behavioral differences, which prevents effectively addressing this problem through patient work at the local and regional level. Another Australian anthropologist refers to it as a “guilt politics” that has led to no discernible improvement in aboriginal life over decades of trying.

I have worked with marginalized populations, and they commonly acknowledge their own responsibility and behavior for their life paths. They often have a better sense, or balance, than academics who lament what they see as the self-blaming attitudes of the poor. They can be hard on themselves, often too hard, given the built-in disadvantages that many have. But when people look back on their lives, they can see their own mistakes. Most of us don’t like assumptions that we are powerless or simply victims of structures. It’s reflexivity and personal interventions that often gives us an understanding and sense of agencytoward the future, as in this effective diabetes prevention program.

Any sophisticated analysis of social problems needs to consider structures, cultures and individual factors. There are scholars who are balanced and have good models, like sociologists Martin Sánchez-Jankowski or Orlando Patterson who write on urban poverty, but they don’t get the attention they deserve. If academics and commentators really want to effectively address social problems, they need to avoid overly politicizing issues and follow the evidence, which often implicates our own practices and habits, as much as it does larger systemic issues.


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