"Homelessness isn't typically thought of as a medical problem, but it often precludes good nutrition, personal hygiene, and basic first aid, and it increases the risks of frostbite, leg ulcers, upper respiratory infections, and trauma from muggings, beatings and rape," they write. They note a report by the Boston Health Care for the Homeless Program, which tracked the medical expenses of 119 chronically homeless people for five years and found that the group accounted for 18,834 emergency room visits, amounting to roughly $12.7 million."
The Institute of Medicine's report wasn't all bad news. In the global health accounting, America has lower death rates from cancer and stroke and is doing a better job of controlling cholesterol and blood pressure. Plus, if you make it past age 75, you're likely to outlive your contemporaries elsewhere.
That said, the results overall are "devastating," Marks says.
So, U.S. News asked him: What would it take to boost the health of Americans, to get to his proposed "culture of health?" What would the halcyon vision of healthy living look like? Marks rattles off a number of components that constitute the dream: "increasing availability of fresh fruits and vegetables, farmers markets nearby, parks that are safe, sidewalks and crosswalks, room for bike lanes in streets," and so on. That's an ideal, he notes, something to strive for, but a destination that's still a long way from here.
But there are fledgling movements under way. In December 2012, Mayor Michael Bloomberg announced that life expectancy for New York City reached a record of 80.9 years. The achievement has been attributed to many of his administration's initiatives, among them, addressing socioeconomic disparities in infant and maternal health, early identification and treatment of HIV, banning trans fats and mandating calorie counts in restaurants, anti-smoking campaigns, and the creation of bike lanes and green space.
In Philadelphia, which has the highest obesity rate of America's 10 biggest cities, the public health department has teamed up with a nonprofit called the Food Trust to establish a "Healthy Corner Store Initiative" to stock corner stores with staples of a healthy diet, such as fruits, vegetables, low-fat diary, and whole grains.
The National League of Cities is working with municipalities to promote better health through parks and gardens, and public education campaigns, for example. And, of course, Michelle Obama has helped lead and support numerous advancements with her Let's Move! program, which aims to address childhood obesity with active living and healthy eating, including paving the way for healthier school lunches.
In the long-term, such efforts can bolster the social systems that promote health—like good education and incomes, communities that support active living, public transportation, and access to quality health care.
Meanwhile, people can get to work on an individual level.
As David Katz, director of the Yale-Griffin Prevention Research Center, likes to say, health hinges on "feet, forks, and fingers" (the last of these referring to smoking). "The power over health resides with each of us as individuals—not with health professionals. We keep waiting for the next Nobel Prize to grant us vitality or longer life, while squandering the power we have to give ourselves those same gifts every day."
But just because we know what's right or wrong for us doesn't mean we make the right choice. Indeed, NIH dollars are increasingly being put toward understanding behavior change.
Because, as Katz and others point out, the culture we live in can make healthy choices that much harder.