The United Health Foundation just released its annual America's Health Rankings. Again, Vermont finds itself near the top of the charts as the second healthiest state. We have ranked #1 or #2 healthiest for seven years running. This is certainly cause for celebration, one for which many Vermonters deserve credit.

At the same time, it's clear that Vermonters are not all equally healthy, as detailed in the 2015 County Health Rankings by the Robert Wood Johnson Foundation and the Wisconsin Population Institute. The number that best predicts individuals' health may not be their blood pressure or cholesterol level, but their zip code. On average, people living in Chittenden, Washington and Addison counties are far healthier than those living in Essex, Orleans and Bennington counties. Closely tied to these health gaps are socio-economic differences on one side of the equation, and health behaviors on the other. Residents of the counties that fare best generally have higher incomes and education, and are less likely to engage in unhealthy behaviors such as smoking, inactivity or poor nutrition.


For example, Essex County residents are twice as likely to smoke as residents of Chittenden County. Years of Potential Life Lost, a strong measure of premature death, is almost twice as high in Essex County as it is in Chittenden County.

A recent analysis from the Centers for Disease Control & Prevention revealed another alarming fact: Death rates among white non-Hispanic Americans age 45 to 54 have been on the rise since 1999. In prior years, death rates in this group had declined by an average of 2 percent per year. Since 1999, the death rate has increased by half a percent a year. The causes of this increase are suicide, drug overdoses, and liver disease (usually alcohol related). This speaks to a generation of people who may have shorter and unhealthier lives than their parents. Not surprisingly, these effects are more pronounced among those with less education and lower incomes. Unfortunately, Vermont mirrors this national trend.

So how do we make sense of this, and what can we do? To start, we must acknowledge that health care does not in itself equal health. It is estimated that only 10 percent of what determines our health results from care provided in doctors' offices and hospitals. While genetics certainly plays a role, the greatest determinant of health by far is behavior: what we eat, whether we exercise, smoke or drink, if we text and drive, use our seat belts, etc. Research demonstrates that behavior is not entirely based on our own free choice, but is highly influenced by education level, income, and by cultural expectations and the ease or inconvenience we have to make healthy choices in our daily lives.

The Institute of Medicine defines public health as "what society does collectively to assure the conditions for people to be healthy." I am happy to say that in Vermont we have begun to use new and innovative public health strategies. We conduct Health Impact Assessments to review new projects and policies for their likely impact on health, and are applying the concept of "Health in All Policies" (HiAP) across all of state government. The goal of HiAP is to ensure that decision-makers are informed about the health, equity and sustainability consequences of various policy options during the policy development process. This approach identifies the ways in which decisions in multiple sectors – such as transportation, agriculture, land use, housing, public safety, education – affect health, and how better health can support the goals of these multiple sectors. The goal is to build a culture of health in our state and assure a healthier future for all Vermonters.

Turning back to the individual, if our behaviors are key to health, this should be an easy fix, right? Sadly, changing behavior can be one of the hardest things to do. We have learned much about how we make decisions, and what's clear is that we as humans are not able to think through our choices and make the best decisions multiple times a day. Imagine going to the grocery store hungry following a tough day at work or with a cranky toddler or two. More likely than not, you will make some less than ideal choices.

Our culture highly values individual choice and resists limiting it. Just the same, we can design our world to encourage better or healthier choices. If there were no candy at the checkout counter, we'd buy less candy. The converse is also true. If healthy options are presented in attractive and conspicuous ways, a person is more likely to make the healthy choice. Designing the environment to nudge us to make the healthier choices must be planned and intentional. Successful strategies we've introduced in Vermont include worksite wellness programs, a robust Farm-to-School network, and a growing commitment on the part of state government to purchase healthy and local food.

Here's a fact: Three behaviors – tobacco use, physical inactivity and poor nutrition – contribute mightily to four deadly diseases – cancer, heart disease/stroke, lung disease and diabetes. These four diseases cause more than 50 percent of all deaths. This is truly a life-or-death issue. We must take on the challenge of building and reinforcing a culture of health in our policies and decisions in government and in our communities all across the state. We can't afford not to do this.

– Harry Chen, MD, is Vermont Commissioner of Health.