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Humans Behaving Badly

Researchers at the Bloomberg School's new Department of Health, Behavior, and Society want to know: If it's bad for us, why do we keep doing it? They've also launched a number of intervention programs aimed at encouraging us to be good.

By By Dale Keiger
Photos by Mike Ciesielski

Begin with a few statements that most reasonable, informed people accept as true: "Smoking damages your lungs and causes cancer." "Obesity is bad for your health." "HIV/AIDS infection can be prevented." "Using a dirty hypodermic needle is dangerous."

Now ponder a few facts. According to the American Lung Association, in 2004, the most recent statistical year, Americans lit 388 billion cigarettes; 44.5 million adults in the U.S. smoked, and 8.6 million Americans suffered from at least one disease caused by smoking. The American Obesity Association says 127 million American adults are overweight, 60 million of them so overweight as to be obese. The Centers for Disease Control report that in 2004, new HIV/AIDS diagnoses in the U.S. totaled 38,730, bringing the number of infected Americans to approximately 950,000. Of those new diagnoses, nearly 6,000 resulted from injection drug use.

The moral is inescapable. People know that certain behavior endangers, even ruins, their health, yet by the millions they indulge in that behavior anyway. They smoke. They eat too much pizza and too many cheeseburgers. They have unsafe sex. They inject drugs, frequently with unclean needles. They do any number of other dumb things. This risky business is hardly confined to the United States. Throughout the world, injurious behavior results in preventable chronic diseases that kill hundreds of millions of people, drain billions of dollars, and cause suffering that cannot be tabulated.

Alfred Sommer, Johns Hopkins School of Medicine professor of ophthalmology and epidemiology and former dean of the Bloomberg School of Public Health, has observed human behavior all of his professional life. "Half the health problems in the U.S. have nothing to do with molecular biology or genetics or viruses," he says. "They have to do with why people behave the way they do."

Five years ago, when he was still the dean, Sommer decided it was time for the Bloomberg School to address human behavior — and all that influences it — in a more systematic, academic fashion. The school had several researchers who studied behavior, but they were scattered throughout the institution. There were redundant course offerings and no real curriculum for students who wanted to concentrate on behavior and health. So Sommer initiated a series of educational presentations to acquaint himself and a wider group of Bloomberg School colleagues with the leading research. He established advisory committees to explore the creation of a new academic department. He courted a donor who liked the idea so much he came through with an extraordinary donation of $20 million.

David Holtgrave, HBS chair, says that to change the behavior of an individual, you have to change social norms. The outcome was that on August 1, 2005, the new Department of Health, Behavior, and Society figuratively hung out its shingle. HBS began life with a chairman, David Holtgrave, recruited from the federal Centers for Disease Control, 20 core faculty members, 67 graduate students, and that $20 million endowment. Its stated purpose is to study how behavior shapes health, how social forces shape behavior, and how public health specialists can intervene to encourage wiser choices.

Says Andrea Gielen, one of the department's founding professors, "Maybe 30 years ago, the discussion would have been about dealing with individuals. We framed everything around individuals because the science wasn't there to say, 'Wait a minute, it's not just the individual.' But it became very clear over a few decades that individual behavior was not a function just of one's own volition, that our behavior is really influenced by a lot of things outside ourselves. It's the [whole social] environment. It's those external forces that ultimately are affecting individual behavior."

The professional phrase applied to this is "the ecological model of illness." A growing body of research has demonstrated that individual free will — should I quit smoking? am I going to eat that second donut? go into drug rehab? — does not exist in isolation, and in many important aspects is not so free. Our decisions are all profoundly influenced by family, intimate partners, friends, neighbors, peers, personal and family history, advertising, economics, politics, and social custom.

Gielen calls herself "an old community health educator." By the end of the 20th century, educators like her faced a discouraging reality: Some of the largest public health initiatives, based on the conventional wisdom of the time, were not producing ideal results. Too many people listened to the advice, read the brochures, and watched the public service announcements on television — then they lit cigarettes and had unprotected sex and risked their health in other ways. While public health campaigns diminished, and in some cases eradicated, smallpox, polio, and many other infectious diseases, some campaigns against major chronic illnesses stalled or failed.

Says Sommer, "Health education has been going on for a long time. 'Brush your teeth twice a day.' 'Don't smoke.' 'An apple a day keeps the doctor away.' That's old stuff. But one thing you have to ask is why do some people eat that apple, and some people do not?"

So researchers, at Hopkins and elsewhere, began to formulate a new ecological public health paradigm. They began to move away from the old model, of marshaling and conveying facts to persuade individuals to make sounder decisions, toward attempts to change social norms. Sommer offers the example of smoking: "In the U.S. we have between 25 and 30 percent of adults still smoking. We've got a long way to go, but that's only half of what it used to be, and it isn't because people suddenly knew that tobacco was bad for you. Back when I was a teenager, we called cigarettes 'coffin nails.' [What happened was] a change in our acceptance of smoking." Over a period of years, at least among some socioeconomic classes, it simply became socially unacceptable to smoke. Gielen cites drunk driving as another example; when it became not just a bad idea but socially taboo to drink and drive, incidence of drunk driving began to decline.

Holtgrave, the department's chairman, says, "Reaching the individual is necessary but not sufficient. When we think about HIV-related behavior, for example, promoting condom use is going to involve talking to individuals. But while talking to people one-on-one may be part of the puzzle, it's not nearly the whole puzzle. If we want to change individual behavior, a very powerful way to do that is to work on the social norms."

HBS researchers study a broad array of public health problems and interventions. Debra Roter devised a system for analyzing medical interactions that is now used worldwide. At Hopkins she employs it to study interaction between health care providers and patients. For example, asthma is a growing problem among inner-city children. Roter has studied what happens when 4- to 9-year-olds go to emergency rooms because of asthma attacks, and found that part of the ecology of asthma in the inner city is kids do not get the information they need from doctors or nurses to manage their condition. Margaret Ensminger has studied the antecedents of drug use, and found that boys who were both shy and aggressive in the first grade were more likely to grow up to be adult drug users; if you want to intervene to keep them from shooting heroin, you may need to address their social behavior when they are in grade school. Katherine Klegg Smith is a sociologist currently studying how news media coverage of tobacco influences youth smoking. Gielen has surveyed women about condom use, and found that public health messages regarding safe sex fail to take into account abusive partners. "The women said, 'It's all well and good to talk about being safe by using a condom, but my partner is not going to let me. I'm in a violent relationship. I'm much more concerned about my safety and my children's safety than your message about why I should use condoms,'" Gielen explains. "It was really kind of a wake-up call."

Now that the new department has a name, an endowment, and a core faculty, it will turn its energies to developing a strong curriculum to attract world-class grad students and to recruiting additional faculty. Holtgrave says HBS wants to develop stronger concentrations in nutrition-related health issues like obesity and diabetes, as well as tobacco control. It has begun a partnership with the American Legacy Foundation, the anti-smoking advocacy group created by the 1999 settlement of the massive litigation brought by state attorneys general against tobacco companies.

Says Holtgrave, "I think we have a historically unique chance, because of the gift from the donor, to move social science and public health another major step forward. This is really a unique opportunity to do that. I'm very excited about where we're headed."

Dale Keiger is a senior writer at Johns Hopkins Magaine.

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