APRIL 24, 2005. More than a decade later, I can still remember how it felt to touch down at Yeager Airport in Charleston, West Virginia. It was a sunny Sunday afternoon, and I was beyond tired. The week leading up to the flight had been a hectic blur—and the six months prior to that hadn’t been any easier. Meetings and phone calls and email exchanges. Countless late nights designing and redesigning documents and tools. Shopping expeditions for clipboards and clicker-counters and computer software. Not to mention packing and repacking heavy cases, trying desperately to make everything fit. But finally we were here: a team of “disease detectives” sent by the U.S. Centers for Disease Control and Prevention (CDC) to investigate the state’s obesity outbreak.
Yes…you read that right. The world’s foremost organization in the fight against the spread of infectious diseases—frightening, highly contagious illnesses such as Ebola and Zika—had sent a group of public health professionals into West Virginia to study overweight people. Okay, so that’s not entirely accurate. What the CDC was interested in—what I was interested in—were the circumstances behind the state’s shockingly high rates of a non-contagious disease: obesity. In 2004, West Virginia ranked third among U.S. states for obesity and first for one of obesity’s consequences: hypertension, or high blood pressure. The state also ranked second for diabetes, another health condition associated with obesity. More than 10 percent of adults in West Virginia had diabetes at that time, compared to about 6 percent in the rest of the country. An epidemic—also called an “outbreak”—is defined as “rates of disease above expected or normal levels.” Based on those parameters, West Virginia was indeed suffering from outbreaks of obesity, diabetes, and hypertension, even when compared to the already high rates of these conditions in the rest of the United States. The question was: Why?
To understand what I was doing in West Virginia—and the importance of the unprecedented work my team was about to tackle—we need to detour into the past.
Once upon a time, I planned on being a doctor—the kind who wore a white coat and carried a stethoscope and spent her days seeing patients. Becoming an expert in the ways our built environment can affect our health wasn’t something I envisioned. I never thought I’d spend my working days (and nights, and weekends!) helping cities and organizations around the world become better at supporting healthy lifestyles. Who could dream that up?
I owe this career to a crisis of conscience I experienced between my first and second years of medical school. Sitting on a park bench one warm, breezeless evening, watching the sky melt into an orange-pink sunset, images of my future flashed before my eyes, depressing by contrast: day after day in a clinic or hospital, white walls and gray doors all around, white fluorescent lights above, white doctor’s coat hanging to my knees. Instead of excitement at the prospect of being a doctor, I was filled with dread and despair. As much as I liked helping people, it depressed me to think of spending all my days within dreary hospital settings, trying to treat patients suffering from diseases that are largely avoidable in the first place. I sat on that bench until the sky turned dark. The next morning, I made an appointment with the dean of Student Affairs and arranged to take a year off. I knew that conventional medicine wasn’t for me; I needed some time to figure out what was.
During that year, I spent a lot of time contemplating the purpose of medicine. I grappled with the question of how a doctor could find meaning in his or her work, especially in cases where no cure was possible. Could meaning be found in helping a patient to face death and face it well, to die in peace? I thought perhaps it could, and I began to think about oncology as a possible specialty. Once again I found myself sitting outside the dean’s office, this time with the summer electives catalog on my lap. I was intent on looking up radiation oncology, but a serendipitous thing happened when I opened the book. Instead of landing at the beginning of the Rs, I ended up near the end of the Ps—the public health page.
Back then, like many other people, I had no idea what public health even was. Certainly, I had no clue that public health existed as a specialty for physicians. But as I ran my eyes down the page, I became fascinated with the range of work in the field: food safety and restaurant inspections; daycare inspections; water safety and sanitation monitoring; pest control (from controlling mosquitoes that could spread West Nile virus to controlling rabies in raccoons); needle exchange to prevent the spread of HIV and other blood-borne diseases such as Hepatitis B and C; outbreak detection and control; vaccination programs. I signed up.
That summer—and in the years of study and training that followed—I discovered that I loved public health. Because of the good work done in this field, almost all of us can now access safe drinking water simply by turning on our taps. We have programs that provide free treatment to anyone who has contracted tuberculosis or a sexually transmitted infection, in order to prevent the spread to others. Patients who have difficulty following directions on medications for treating tuberculosis are even visited and assisted by public health nurses, ensuring that their illness is treated fully and that antibiotic resistance does not become an issue with our most deadly infectious diseases. And we can monitor these diseases in all of our communities, helping to detect emerging outbreaks and stop them quickly.
Public health, while firmly grounded in science, is also about creativity and innovation—a combination that appealed to the young medical student I was, and still appeals to me today. An example: In 1854, the Soho district of London was in the grip of a deadly cholera outbreak. At the time, the medical profession believed the disease was caused by “miasma,” a cloud of infected air that rose from garbage and sewage piles. Dr. John Snow wasn’t convinced. He thought that cholera’s severe diarrhea might be caused by something people ingested, and that it was possibly passed along not through a cloud of toxic air but through traces of infected feces.
The outbreak gave Snow a chance to test his theory. He visited affected neighborhoods and knocked on doors, questions at the ready: How many people in the house have fallen ill? How many have died? Where do you get your water? Slowly, painstakingly, he mapped the outbreak—and the information he gathered led him to a water pump on Broad Street. It is said that Snow stomped over to the pump and yanked off the handle. With or without that dramatic flourish, his approach worked. The outbreak stopped. At a time when society had few effective ideas regarding how to control infectious diseases, John Snow—the “father of epidemiology”—studied the problem and then implemented a solution based on outside-the-box thinking.
Snow’s water pump moment was a decisive victory in the fight against infectious diseases. Around the world, cities took note and began implementing important changes to address sanitation, water and food supply, and living conditions (from overcrowding to proper ventilation and light). New zoning requirements allowed sunlight in to dry out previously perpetual puddles and damp streets that bred disease-carrying mosquitoes. Swamps were drained. Pest control became a priority. The results were dramatic. From the middle of the nineteenth century to the early twentieth century, deaths from infectious diseases like cholera and tuberculosis dropped significantly. With the introduction of vaccines, like those for smallpox and measles, and the creation of programs that provided easy access to them for little or no cost, infectious disease rates dropped even more dramatically. People began to live longer lives.
I loved these “success stories,” and I was inspired by the comprehensive, environmentally grounded, systems-based approach that public health brought to the practice of medicine. I loved the idea that there was a “common good,” and the notion that it made sense for governments and health organizations to intervene in order to ensure that people had the support they needed to stay healthy and safe. I loved that when these interventions worked, people didn’t have to get sick in the first place, and those who were sick could be helped. This was the meaning I’d been looking for during my year off. I’d found it in the study of public health, and I looked forward to applying the discipline’s models to the health challenges of our times.
It’s hard to believe from today’s vantage point, but there was a time when obesity wasn’t considered to be the health crisis it is today. Although it had been identified as a key risk factor for cardiovascular diseases in the 1960s, U.S. data from that era suggested that obesity occurred in only a very small percentage of the population. Very few people had a body mass index (BMI)—or weight-to-height ratio—of 30 or higher, the level at which one was considered to be obese. In the 1980s, that would change. That was the decade in which we’d realize just how quickly rates of obesity—and with them, cases of diabetes—were rising.
One of the first to discover this was Dr. Bill Dietz. In 1970, Dietz graduated from the University of Pennsylvania with a medical degree and became a pediatrician, training in Syracuse, New York. He eventually made his way to Boston, earning a PhD in nutritional biochemistry from the Massachusetts Institute of Technology in 1981. Soon after his training ended, Dietz’s reputation as an expert on obesity—particularly childhood obesity—took off. In the 1980s, he began documenting the rapid rise in childhood obesity rates in the United States. From his published research, we would learn that by the late 1970s, the condition of being overweight had increased by 39 percent for those between twelve and seventeen years old, and “superobesity” (the term used by Dietz for what we call childhood “obesity” today) had increased by 64 percent. We would learn that the situation was even worse among younger children, with overweight increasing by 54 percent and superobesity by a staggering 98 percent since the 1960s for those aged between six and eleven. In 1984, Dietz’s research showed that obesity rates had seasonal and regional differences. And in 1985, he published the first study showing the links between television watching and obesity in children. TV viewing, it would turn out, promoted sedentariness and inactivity as well as unhealthy diets. Unhealthy food consumption—kids stuffing their mouths with chips, cookies, and popcorn as they sat on the couch—was a big part of the dietary issue, but children who watched a significant amount of TV were also watching more food advertising, which would push them to nag their parents for the unhealthy but tantalizing items they had seen on their screens. In 1986, Dietz’s research showed that once a child was obese, treatment tended not to work. Prevention, he concluded, was the best defense.
Dietz’s research stuck with me as I made my way through school. By the late 1990s and early 2000s, as I worked my way through my Master of Health Science degree and residency training in Public Health and Preventive Medicine at the University of Toronto, the obesity epidemic was spiraling out of control. Rates of obesity and overweight had been rising for more than two decades, and there was no end in sight. In both Canada and the United States, obesity had doubled in adults and tripled in children since the 1970s and 1980s. Health care costs associated with obesity and its consequences, particularly type 2 diabetes, were rising rapidly. Obesity urgently needed a solution.
In my brain, something was starting to percolate. Over the years, I had taught myself to think laterally, to use analogies from one field of study to find possible solutions in another. Now I found myself wondering: Was there a link between Dietz’s TV-watching kids and the Soho residents who got their water from a contaminated pump back in 1854? Could we apply lessons from our public health successes of the past—successes that had tackled infectious diseases like cholera and tuberculosis by adapting the environment—to modern, non-contagious health problems like obesity? I was determined to find out.
Unfortunately, I wasn’t finding much support. All around me, public health professionals were throwing up their hands in the face of ever-worsening obesity and type 2 diabetes statistics. They were at a loss. The health education messages spread through ads, posters, pamphlets, and the media didn’t seem to be making a difference, and a general sense of hopelessness had set in. In health department after health department during my residency, I saw few examples of effective work. On several occasions, I even heard colleagues question whether the obesity and diabetes epidemics were their problems to solve. They wondered if perhaps people were just too lazy or lacking in willpower to stick with healthy-living habits. If that was the case, they reasoned, then maybe there was nothing to be done.
Although this wasn’t a conclusion I was prepared to accept, I was running out of places to look for allies. At one point, my residency program director suggested I meet with a researcher to discuss my ideas for a thesis project. I was excited at the possibility of finding a kindred spirit, someone who felt as passionately as I did about the potential for finding a solution to the obesity and resulting chronic disease epidemics in the public health successes of the past. But it didn’t go as I’d hoped. I presented my ideas, only to have each one shot down. The researcher responded to an approach I thought was particularly promising with, “Even the crackpots are not studying that.”
I left the meeting discouraged but not defeated. I held on to Albert Einstein’s observation: “Great spirits have always encountered violent opposition from mediocre minds. The mediocre mind is incapable of understanding the man who refuses to bow blindly to conventional prejudices.” I knew there was a link between our environment and our increasing levels of obesity, and I knew I wasn’t the only one who had noticed. Several studies from the 1990s already showed this. In 2001, the U.S. Community Preventive Services Task Force, convened by the Department of Health and Human Services, conducted and published a review of the studies into how different community actions impacted the risk factors for obesity like physical inactivity. It confirmed that media campaigns alone were not effective in battling our growing waistlines: there was insufficient evidence that they worked.
But the review also revealed something else—something intriguing. Comprehensive community campaigns were effective. When we tackled the problem with a holistic approach—coupling those health messages with changes to the environment in which we lived and worked—people seemed better able to alter their health behaviors. In 2005, the same task force would build on those findings, recommending changes to the ways we construct our streets and communities. New scientific evidence had proven that better, more health-conscious design of human-built environments was associated with astonishing increases—between 35 and 161 percent—in regular physical activity. When streets and neighborhoods were designed for people to walk and bicycle, and to do so safely, they walked and bicycled more. When people had access to physical activity facilities, from playgrounds to parks to walking paths, they got more physical activity and maintained healthier weights. When buildings were designed to encourage healthy choices, such as taking the stairs, people embraced the better options.
Finally, the research was converging with my own efforts to take a public health approach to obesity and its consequent chronic diseases. With the task force’s recommendations, the public health field was finally ready to consider a comprehensive approach that included addressing the environments in our buildings, streets, and communities that either supported or were barriers to our healthy life choices.
By the time the U.S. Community Preventive Services Task Force released those recommendations in 2005, I was well on my way to making a career out of helping cities and organizations support healthy living.
Following the completion of my medical training in 2001, I left Toronto in search of a more supportive environment and found it in Edmonton, Alberta. Between 2002 and 2004, I worked in the local public health department as a deputy medical officer of health in charge of non-communicable diseases (NCDS). Among my responsibilities was participation on the steering committee of the Countrywide Integrated Non-communicable Diseases Intervention (CINDI) project. This World Health Organization (WHO) demonstration project was exploring what could be done to address our current epidemics of non-communicable diseases in one locale, this time Alberta, Canada. CINDI would end up creating the Alberta Healthy Living Network, convening over 150 organizations in the province: local and provincial public health departments; non-governmental organizations such as the Heart and Stroke Foundation, the Canadian Cancer Society, and the Canadian Diabetes Association; academic institutions; and even those working in and outside the government in education, recreation, and other related fields. These groups—all with different mandates and goals—were expected to work together to reduce key risk factors such as smoking, physical inactivity, and unhealthy diets.
I attended one of the group’s first meetings. Roughly twenty of us sat at a large wood-paneled conference table, a breakfast of fruit salad and bran muffins before us, in a windowless white room lit by fluorescent bulbs. In contrast to the drab surroundings, not much livelier than many of the hospital settings I had encountered in medical school, the people themselves were enthusiastic and excited. High hopes were pinned on the project to create change in Alberta. Some of those present had been working for a long time in non-communicable disease prevention. Some spoke of inertia, and of the lack of partnerships and coordination across organizations, all of which were working in their own silos. Others spoke of the need to move beyond health campaigns, which were increasingly showing themselves to be both expensive and insufficient. The first task, we were told, was to make a plan: What could we do together, and how could we do it?
Drawing on past initiatives, the plan we formulated outlined a multipronged approach. This would include providing the public with more information; educating the professionals who could provide support through counseling in health care settings; challenging government and organizational policies to create environments more supportive of health in our communities, workplaces, and schools; and measuring our impacts.
My task was to co-chair the Surveillance, Research, and Evaluation Working Group. Surveillance, in the context of public health, is a term used to describe the monitoring of disease rates, trends, and risk factors using epidemiological methods. Typically, surveillance has been restricted to serious infectious diseases, for which the law actually requires doctors, hospitals, and laboratories to report occurrences to public health departments for tracking. Today, reportable infections include blood-borne diseases such as HIV and Hepatitis B and C; sexually transmitted infections such as gonorrhea, syphilis, and chlamydia (in addition to HIV and Hepatitis B); tuberculosis and influenza; water-borne diseases such as cholera; food-borne diseases such as salmonella and E. coli infection; and animal- and insect-transmitted diseases such as rabies, plague, and Lyme disease. It is through such reporting, and the regular monitoring of disease rates and trends in our communities, that outbreaks of these infections are often identified, ideally early enough to prevent further spread.
Surveillance for non-communicable diseases and their risk factors, on the other hand, is not undertaken in many communities. Although national surveys were being conducted in Canada at that time, and annual state-level surveys were occurring in the United States, the data needed for monitoring NCDS and risk conditions such as tobacco use, obesity, physical inactivity, and poor diets within communities was at the time—and still is—largely lacking. I knew we needed to get to work on building this community-level information. It is vital for understanding a community’s specific needs, and for determining whether various public health actions are having the desired effect.
We were making good progress in Edmonton, and I loved the creative, cooperative, proactive nature of our work, but an irresistible opportunity was on the horizon. In late 2003, I traveled to Atlanta, Georgia, for an interview with the U.S. Centers for Disease Control and Prevention’s Epidemic Intelligence Service (EIS). The EIS is an elite team of scientists, medical doctors, and PhD-level professionals—the “disease detectives”—assembled by the CDC and rotated every two years to all corners of the United States, and even the globe when needed, to investigate disease outbreaks and bring them under control. Formed in 1951, the EIS fights on the frontlines of public health. To date, more than three thousand men and women have been deployed. To highlight the division’s field-based nature and focus, the imprint of the sole of a shoe has been used as its symbol; field epidemiology is also called “shoe-leather epidemiology.” In many ways, this was my dream job—a chance to work for one of the world’s largest and most respected public health organizations, a chance to put all of my training to use.
I remember sitting outside the director’s office waiting for my interview and offering up a silent prayer: Please let me think clearly. Please let my responses be knowledgeable and interesting, yet humble. It must have worked: a few months later, I learned I was one of roughly a hundred candidates from the United States and around the world to be accepted into the disease detectives program.
On a warm, sunny day in June 2004, with my father along for the ride, I climbed into my black, two-door 1999 Honda and began a five-day drive. We traveled south to Montana through the snow-peaked mountains of Glacier National Park, then through Yellowstone, past its blowing geysers and bison herds. We emerged east of the red mountains of Wyoming and headed for the long stretches of flat plains in South Dakota. We took a short detour to see the four presidents carved into Mount Rushmore—inspiring to two Canadians, and an appropriate preparation for my life in the United States—and then continued to Illinois, where we stopped for our first visit to Chicago, a relief after two days of nothing but dry grass, cattle, and farmhouses on the horizon. Then Nashville, which we were too tired to tour. And, finally, Atlanta.
Hot, humid, sunny weather greeted us. Lush with trees and foliage, Atlanta is a city of about half a million residents located within a metropolitan area of suburban sprawl whose combined communities raise the population to over four million. With my father’s help, I quickly found an apartment in the Virginia Highlands area, only a block from Piedmont Park—the beautiful in-town green space designed by the sons of New York’s Central Park designer Frederick Law Olmsted, and one of two areas in Atlanta at the time that had walkable streets that would take me to nearby restaurants and even an art-house movie theater. I was thrilled that the apartment complex also had an outdoor swimming pool. My first day of work arrived, my father flew home to Canada, and I headed to the CDC.
Although EIS is a separate program within the CDC, its officers are deployed throughout different divisions. Most work within the Center for Infectious Disease Control, some focusing on improving the prevention and control of long-standing infections such as tuberculosis or sexually transmitted diseases or water-borne diseases still rampant in the developing world. Others work on emerging infections such as new strains of the flu. Still others dedicate themselves to rare but scary diseases like Ebola. Only a handful are assigned to the National Center for Chronic Disease Prevention. This was, in fact, my assignment of choice. I had chosen the Physical Activity and Health Branch within the Division of Nutrition, Physical Activity, and Obesity in order to work on the environmental and policy-change projects they wanted to undertake to boost physical activity and improve obesity and chronic disease rates in the United States.
On that first day, I was shown to my office on the fifth floor of a mid-rise building covered in black reflective glass at CDC’S Koger Campus, one of a number of campuses across Atlanta where CDC located its employees. A small, windowless office sparsely furnished with a desk, computer, phone, and rolling chair would greet me daily from 2004 to 2006. I was eager to get to work, and eager to partner with Drs. William Kohl and Michael Pratt, whom I’d met at a conference a few months earlier. An important factor bound Bill and Mike together, and me with them: we shared a drive for finding creative new ways to help support people—and the local and state health departments that were, in turn, trying to help them—to achieve their health goals around behavior change, obesity, and non-communicable diseases. One of the things I loved most about my time working with the Physical Activity and Health Branch was the sense that we were aligned in our willingness to take risks, to identify or create new solutions grounded in emerging science. We were optimists who believed fervently that if we tried, we could find answers even to seemingly intractable current-day epidemics like obesity and diabetes. For the first time in my life, I felt free to voice my many ideas, including some I’d started exploring as far back as my time in Toronto. I felt appreciated for being creative and innovative. I was not only supported but also encouraged to pursue the ideas that “even the crackpots” were not pursuing. In fact, one of those ideas was about to become a reality.
Like all new CDC EIS recruits, I spent my first month on the job in an intensive EIS course. We learned about our DISC (Dominant, Influential, Steady, Conscientious) personality types, and how important they were to our success as a team. Since many of us had not had formal management training at that point, it was probably the first time that we’d started thinking about how to make our teams more effective with people of different personalities: Dominant people, who could make decisions in the face of uncertainty; Influential people, whose team interactions influenced people positively; Steady people, who would ensure the supports for getting things done well; and Conscientious people, whose constant analyses and quests for data would ensure that details did not get missed. We learned the epidemiology methods and computer programs we’d be using in our work. We did mock field studies to prepare us for the real outbreaks that we’d soon be expected to help investigate and bring under control.
It was at this course that I met Julie Sinclair. Julie was a quiet, soft-spoken brunette with thick, shoulder-length hair, slightly taller than my five foot three, and perhaps a few years older than I was. Julie was in Atlanta for the course but had recently moved to West Virginia for her two-year CDC assignment as their state health department’s EIS officer. My ears perked up when I heard that. West Virginia: home to some of the worst obesity rates in the country. Like most EIS officers, Julie was assigned to assist her health department’s infectious disease division to better monitor, investigate, and control epidemics. Obesity, hypertension, and diabetes—all non-communicable diseases—weren’t in her job description. But I wasn’t about to let that stop me. I wanted to get my boots on the ground in West Virginia. I wanted to get up close and personal with the environments in which obesity and its related consequences were thriving. I wanted to answer that all-important question—“Why?”—and the equally important “What can we do about it?” Julie was my “in”—an ally on the ground, if she was willing to help.
She was. In order for the CDC to bring a team to West Virginia, we had to be invited. Julie got it done. She connected me to obesity prevention staff working in the state’s Bureau for Public Health. I would soon find out that the timing of that call was perfect. West Virginia was in the midst of developing a plan to address its obesity problem, and it needed more data to determine where it should focus its interventions. Was it schools? Worksites? Community settings like restaurants and grocery stores? And what items in those settings needed to be addressed? Where were the barriers to physical activity and healthy eating? Was the environment supportive of the behavior changes people needed to make to conquer obesity?
Not long after those initial conversations, West Virginia’s state health commissioner sent a formal request to the CDC’s Epidemic Intelligence Service: Could we please send a team to West Virginia to help investigate the state’s obesity “outbreak”? CDC leadership approved the request. The “crackpot idea” was finally in motion.
Our touchdown in Charleston was the culmination of months of hard work. Because we were applying outbreak investigation methods to non-communicable disease conditions, something that had rarely been done before, we needed to reinvent the wheel. We had to find—and in some cases develop—the data collection tools and methods we’d need. Tackling that monumental task with me were epidemiologists Dr. Andrea Sharma and Dr. Michele Maynard, who worked on nutrition issues at the CDC, and Dr. Candace Rutt, the CDC’s resident scientist specializing in the built environment and physical activity. Together, we developed the surveys and observational recording forms we would use to assess the healthiness of the environments in West Virginia schools, worksites, restaurants, grocery stores, and convenience stores, and the streets that surrounded them.
Next up: figuring out where to go. Our West Virginia Bureau of Public Health colleagues had recommended that we focus our assessments on the city of Clarksburg-Bridgeport and the more rural Gilmer County. Clarksburg-Bridgeport, with a population of twenty-eight thousand, was considered a large city by West Virginia’s standards, and it was hoped that our findings there would give us an idea of how well the state’s larger cities supported physical activity and healthy eating. Gilmer County had only seven thousand residents; it would give us an indication of how a small, rural county was faring.
While we finished our preparations in Atlanta, the West Virginia Bureau of Public Health staff called the local health departments in Clarksburg-Bridgeport and Gilmer County. Both departments gave the nod, but informed us that they would not be able to participate in the fieldwork—they were too busy with bioterrorism planning.
Bioterrorism? West Virginia had the highest rate of hypertension, the second-highest rate of diabetes, and the third-highest rate of obesity in the United States, but the local health departments had no capacity to join a three-week effort aimed at an investigation to address the situation? I was incredulous. While increasing numbers of people were dying from these debilitating and dangerous health conditions, local health departments were engaged in planning for bioterrorist activity with infectious disease agents that in all probability would never be used to target a small rural county.
This was frustrating, to be sure, but nothing unusual. With funding scarce, health department officials frequently “follow the money.” If there’s funding for bioterrorism preparedness, staff will be hired and put to work. In both the United States and Canada, funding for local health departments to address chronic disease is often nonexistent, except through limited grants. It’s an imperfect system, given that finding and then applying for those grants is a labor-intensive process. As a result, many limited-capacity local health departments—which are all too often found in areas with the highest rates of NCDS and their related risk factors and conditions—are unable to put energy into getting the non-routine funding for fighting those NCDS. Instead, they spend their time creating or maintaining programs from the long-standing funding that is routinely provided to them only for the control of infectious diseases.
It would have been nice to have the help of the local health departments, but the lack of it wasn’t going to stop us. We buckled down and prepared for our three weeks on the ground. In each locale, we chose a representative sample of schools, worksites, restaurants, grocery stores, convenience stores, and streets. We looked for tools used in previous studies to observe the offerings of foods and beverages in stores and restaurants. We looked for tools used to interview worksite and school staff. We used Google Maps to plot a one-quarter-mile radius around each school and the ten largest worksites. Those maps were then printed onto eight-by-eleven sheets of paper and placed on an ever-growing stack. Next came the painstaking work of numbering every street segment, the section of street between any two intersections. These hundreds of numbers would eventually correspond with the worksheet that at least two people in the field would complete for every segment, assessing and recording measures associated with walkability: sidewalk width and conditions, traffic speed limits, the number of cars speeding by, and land uses (what types of buildings sat on those streets and what services they offered).
Finally, we figured out our staffing needs. Since the EIS program generally supported a maximum of twenty-one days in the field for outbreak investigation teams, we needed to estimate how many people it would take to complete the work within that timeframe. We concluded that two to three team members from the CDC along with several people from the West Virginia Bureau of Public Health would do the trick. Andrea Sharma and I would be on site for the entire three weeks. Judd Fleisch, a medical student doing an elective with the CDC, was keen to accompany us for the first half of our trip, and Michele Maynard—a native of Gilmer County—would take over when Judd had to leave.
On our first morning in Charleston, Judd, Andrea, and I made our way to the West Virginia Bureau of Public Health. We were greeted in the lobby by Kerry Kennedy, director of the bureau’s obesity program. She brought us upstairs to a conference room filled with twenty or so people, a combination of her staff and volunteers from other programs who were eager to head into the field with us. Some of Kerry’s core staff would be with us almost daily over the next three weeks, while others would pitch in for one morning or afternoon. They would provide the additional help we needed, and, in turn, they would be trained in field data collection methods.
This was our only training day, and we had no time to waste. Not only did our volunteers need to learn how to use our data collection tools, but some of the tools themselves also needed final testing with field staff. On this first day, we learned that our restaurant audit form wasn’t up to snuff. Our plan had been to look at the menus and use the form to capture information like the number of entrées on offer with one, two, or three servings of fruits and vegetables. That proved a nearly impossible task. Menus often don’t accurately describe what’s served in the main course, and rarely do they reveal how much of a side will be served. So, even if carrots are listed as a side, we could rarely tell if there would be a ¼ cup (half serving) or a ½ cup (full serving) of sliced carrots, or even just a garnish of one or two carrot sticks arranged on the plate. Andrea and I looked at each other and shook our heads. Why hadn’t we thought of this? We’d run out of time in Atlanta before we’d had a chance to test this final tool. We’d just assumed it would work, since it had been used in a previous study. We’d never thought about the difficulties in garnering such quantified information from a menu.
We had to come up with a different form—and fast. Luckily, West Virginia’s Bureau for Public Health had developed a menu assessment tool for a previous study. Kerry walked to her office, clicked through her computer files, and came back with the form in hand. We all sat down to review it, surrounded by the take-out menus we had gathered that day. We compared the form’s list of items to record with the information available on the take-out menu of a pizza-and-pasta joint. Very quickly, we realized we needed to remove items such as “preparation methods” from the form. Were the potatoes that came with the chicken marsala deep-fried, pan-fried, roasted, or boiled? We couldn’t always tell. We also decided to add a few questions for restaurant staff, to help suss out information that might not be available on the menu. For example, we’d found that although the restaurants we’d visited that afternoon all had milk on hand, it was rarely listed on the menu. But if you asked your server, they would happily tell you what types were available (whole, 2 percent, 1 percent, skim, chocolate!) and bring you a glass.
Our first day ended on a high note. We’d practiced, tested, and revised. Our staff and volunteers were ready to go, and we believed that our tools were now the best they could be for the tasks at hand. We headed back to the hotel, confident that we were ready.
Our first stop was Clarksburg-Bridgeport. After two hours of uneventful highway driving through hilly, green terrain, Andrea, Judd, and I arrived at the Holiday Inn that would be our home base for the next week and a half. At the time of our visit, Clarksburg-Bridgeport, in Harrison County, was a city of twenty-eight thousand residents. It had fifteen public schools and housed seven of the ten largest worksites in the county. Prior to the field visit, the West Virginia Bureau of Public Health team had contacted all fifteen schools: eight had agreed to a visit, five had refused, and two did not return their calls. The bureau had also contacted five additional Harrison County public schools, nearby but outside of Clarksburg-Bridgeport. They’d managed to reach only three of the seven large worksites, and two of those had agreed to participate. Both were private-sector worksites. One employed more than five hundred people, the other more than eighteen hundred. Appointment dates and times were set.
West Virginia is known for its many “hollows,” and Clarksburg-Bridgeport is nestled in a large valley between rolling, tree-covered hills. The city was settled in the 1770s, and its long history is reflected in its gridded street pattern and old and narrow two- and three-story brick buildings in the downtown core. Where old buildings had been torn down, the streets had been widened and much larger and bulkier mid-rise concrete structures had been built. As we made our way to our two worksites, the small, pedestrian-friendly storefronts of downtown gave way to very large facilities. One of our sites was a nondescript multi-story building, the other a sprawling single-story operation. Both housed frontline staff, support staff, and managers.
As tour guides showed us through the sites, we asked questions and made note of what we saw. In the multi-story facility, there was no encouragement for people to use the stairs (lack of even inexpensive signage is a common problem in North American buildings). Despite the size of the two employers—and their building sites, where space did not appear to be at a premium—no onsite exercise or shower facilities were available, and there were no policies to support employee fitness (although one worksite did subsidize employee gym memberships, an offer that studies show is generally taken up by only a small percentage of employees). Both sites fared better on nutrition supports, with lunchrooms and cafeterias providing salad offerings. One of the two also offered other vegetables, fresh fruit, and low-fat items in the cafeteria, and provided nutrition information.
Our school visits followed a similar pattern, though without the tour guide. Upon arrival, our team would typically head to the main office, where we’d interview the principal or assistant principal, as well as the physical education teacher and the food-services manager or personnel. We asked questions we thought would capture the healthiness of the foods served; specifically, we asked about the deep-frying of foods in the school kitchens. Without fail, we were told that no deep-frying occurred. If we were visiting over the lunch hour, we’d then observe as food was served in the cafeteria, and this tended to be an eye-opening experience. When we saw the cafeteria items and menus, it became clear that the schools were routinely serving items such as chicken nuggets, french fries, and corn dogs. When we’d asked about the cooking methods, the staff had responded as though they were doing the cooking; in reality, the meals served were essentially pre-cooked food items, many battered and pre-fried, that the school food staff would then bake to heat up and serve.
We noticed that most of the schools had vending machines for students, and that none contained fruit or vegetables. The most commonly observed items were potato chips, cookies, cakes, and pastries. The beverage machines were no better. They usually featured colorful, branded advertising from the company that supplied the machine and were stocked with sugar-sweetened sodas and fruit drinks. Some also had fruit juice and water. We asked ourselves why children needed to buy water that could be provided out of a tap, especially since there were no drinking water safety issues in Clarksburg-Bridgeport. Fruit juice is no longer recommended for children by the American Academy of Pediatrics since it contains mostly sugar, though it’s naturally occurring sugar, and sodas and fruit drinks are certainly not recommended. So why would schools provide such machines? We asked the principals. They confessed—some sadly, their ears flushing red with embarrassment—that the money from the vending machines was used to help fund field trips and extracurricular activities. As it turned out, not only did the schools receive the machines for free, but they were also paid by the companies supplying them and advertising on them. Though well-intentioned, the fundraising efforts undertaken by these schools—including drives that routinely sold chocolate, candy, and cookies, but almost never fruits or vegetables—were putting children at risk. What chance did these kids have to make healthy choices?
Leaving the cafeteria, we’d make our way through locker-lined hallways to the gym. We’d ask the physical education teachers how much PE time their school offered. Thanks to our background research in Atlanta, we knew that West Virginia had recently passed legislation requiring elementary schools to provide at least thirty minutes of PE at least three days per week, while middle schools needed one full period per day for one semester each year (raising the question, “What about the other half of the school year?”), and high school students were required to take at least one full-credit course. While these requirements were woefully inadequate when compared to the recommendations of the National Association of State Boards of Education (NASBE)—which at the time called for 150 minutes or more per week of PE at elementary schools, and at least 225 minutes per week at middle and high schools—the majority of schools we visited still did not meet them. In fact, not a single elementary school we visited met the state requirements, and no high school met NASBE recommendations nor did they offer PE at all in the four years of study. We were certainly a long way from the U.S. Department of Health and Human Services guidelines that tell us children and youth should get at least sixty minutes of moderate- to vigorous-intensity physical activity every day in order to be healthy. It seemed that the schools in West Virginia—where the children spent most of their days—were not doing their part to support a physically active lifestyle.
When we pulled out our audit forms to document the physical activity facilities, we found that while the majority of schools had a gymnasium, some did not. Some had no outdoor play areas, though these were in the minority. On occasion, we were struck by how the paltry general PE programming at some schools contrasted with the state-of-the-art facilities geared toward the training and performance of their prized athletes. The takeaway? If you were athletically inclined and exhibited a talent for sport, you’d be encouraged to get even fitter; if not, you’d get few supports to get and stay fit and would, in all likelihood, gain weight over time.
We also inquired about whether students could easily walk or bike to school. The vast majority of schools reported hazards for walking and bicycling, with the amount of traffic and traffic speed at the top of that list. A lack of bike trails was also a commonly identified issue, and in the more rural areas just outside of Clarksburg-Bridgeport we heard about an inadequate number of sidewalks. When schools actually had a walking or bicycling policy, these policies usually prohibited walking or cycling to school, owing to concerns about road safety.
Amid these depressing findings, our team took to the streets and sidewalks ourselves. We audited every street segment we had mapped out. Back in our planning stage, we’d chosen to focus on the quarter-mile radius around our sites, since previous studies had shown that most people were willing to walk to a destination if it was no more than five or ten minutes from their home or worksite. At regular adult walking speeds, five minutes usually corresponds to a quarter-mile, and ten minutes to a half-mile.
We assessed a total of 692 road segments in Clarksburg-Bridgeport. On sunny days, on cloudy days, on drizzly, gray days—dressed in our usual working attire of khakis or jeans, T-shirt layered with sweatshirt layered again with a wind-blocking, water-resistant shell, and an extra poncho in our backpacks just in case—our teams would head out to a school or worksite, even the ones that had refused an interview. There, we’d pull out the maps we had prepared with the numbered road segments. We’d walk the lowest-numbered segment first and then move up sequentially. We’d stop at a mid-block position that allowed us to observe most of the street between two intersections. Then, we’d start to record data. What types of buildings were around us? Was there housing close enough to a school to allow children to walk or bike? What about near the worksites? Was there a mix of housing types such as single-family homes and apartments? Buildings that house multiple families, like apartments or townhomes, increase the population density of a neighborhood, and population density, in turn, often increases the likelihood that services settle in and survive. Were there other offices and services in the area? Were there parks, playgrounds, recreation facilities? Banks and dry cleaners and post offices? What about grocery stores, convenience stores, and restaurants that kids in the school or adults in worksites could walk to? We found that 60 percent of the worksites we visited had restaurants within a five-minute walk. That was the good news. The bad news was that unhealthy food choices abounded: the majority of schools had convenience stores nearby, and a third had fast food restaurants within a five-minute walk. Of the worksites, 80 percent had convenience stores clustered around them, double the number that had grocery stores nearby.
We also recorded the conditions of the buildings. Were they boarded up or deserted, leading those who might walk by to feel unsafe? We checked for streetlights, which of course are vital for visibility and safety at night. We noted posted speed limits, and pulled out our clicker-counters to measure traffic volume. We’d check whether or not there was a sidewalk; if there was, we’d pull out our tape measures to record its width and make notes on its condition. Was it well-paved or cracked, clear for walking or full of obstructions, like posts and trees, that would pose barriers for people with walkers, wheelchairs, and strollers? We found that over one-third of the street segments around schools had no sidewalks, and even when sidewalks were present, about 40 percent had only poor or fair walkability. Things were even worse around the worksites, with nearly 90 percent of street segments lacking sidewalks.
Grocery and convenience stores were also on our list. We’d hit the produce section first, to count the varieties of fresh vegetables and fruits available. We recorded their appearance. Did they look fresh and enticing, or were they old and wilted? Next up were the meat aisles, to document whether the supermarket offered alternatives to higher-fat and red meat animal protein, like skinless chicken breasts, ground turkey, and fresh fish. We looked for whole wheat and high-fiber breads as alternatives to white bread. Finally, we headed to the dry goods shelves, on the hunt for items like whole wheat pasta as high-fiber choices. We used the same audit form at convenience stores, where we noted just how different the offerings were. For the most part, we found no vegetables, no fruit, no healthier options like high-fiber grains, but lots of chips, cookies, and soda.
Finally, we audited the area’s restaurants. We’d ask for an eat-in menu and a take-out menu. Where the two were identical, we’d leave with the take-out menu and complete our audit forms in the car or back at the hotel. Where the menus were different, we would conduct the audit there. In fast food restaurants, we stood where we could see the menu board and filled out our forms, straining our necks to peer over the sometimes long lines of customers. Fast food restaurants comprised about half of the restaurants audited in Clarksburg-Bridgeport, with the other two major categories being “pizza” and “casual dining.” We found that while many restaurants offered vegetables, not all did, and few offered fruit, healthy messages, or nutrition information. On the other hand, many offered “supersized” options.
Each evening, we returned to our hotel weary from walking. After dinner, Judd, Andrea, and I would convene in whatever room was serving as our “headquarters.” We’d boot up our laptops, scoop up about a third of the day’s completed forms, and start entering the data into the Excel spreadsheets and databases we’d created. It would be close to or after midnight when we’d finally say good night. Back in my own room, I’d fall asleep as soon as my head touched the pillow.
After a week and a half in Clarksburg-Bridgeport, we had completed our assessments. Our findings were telling. We’d learned that the majority of schools had not implemented the new state requirements for physical education, even though these standards were already well below national recommendations. We found that school cafeterias served many pre-fried frozen foods to their kids, and that on-site vending machines stocked with unhealthy choices and featuring paid advertisement of sugary drink products were used as fundraising vehicles. We found that many schools—and worksites—were surrounded by convenience stores and fast food restaurants that provided yet more exposure to unhealthy foods. We found that supermarkets—which did carry many varieties of healthy products like fruits and vegetables—were less available near schools and worksites than convenience stores, which carried none of these healthy foods. As for walking and bicycling for transportation, the schools that had policies on these items actually prohibited or discouraged these active transportation modes, citing hazards like traffic volumes and speeds, and inadequate sidewalks and bicycling trails. Worksite lunchrooms and cafeterias did provide salad offerings, but not necessarily other vegetables or fruits, or nutrition information. Supports for active living—even inexpensive signage to encourage stair use, or provision of onsite spaces for exercise within large work buildings—were also lacking.
After a week and a half of surveying Clarksburg-Bridgeport, we had to wonder: Would rural Gilmer Country tell us a different story?
Midway into our three-week adventure, we drove through the warm morning, a slight haze in the air. We cut through foothills and more hollows as we neared Gilmer County and Glenville, its main town. Though the scenery was beautiful, the poverty of some of the land’s inhabitants was apparent.
We’d received permission to visit four of the ten largest worksites in the county. All were multi-story buildings. Three of the four had elevators. None encouraged people to use the stairs with signage (which all the evidence indicates is an effective intervention), but two provided shower facilities and three had both onsite indoor exercise facilities and fitness-oriented programs for their employees. All provided staff lunchrooms, and one had a cafeteria that reported offering salads, fruit, low-fat items, and nutrition information.
Four of the five schools in Gilmer County were elementary schools; the other was a combined middle and high school. We were impressed to find that none had a vending machine selling snacks, and only one had introduced a vending machine with beverages. Although none of the schools met NASBE recommendations for PE, all of the elementary schools met the recently passed state requirements. All had a gymnasium, and most had outdoor play spaces. All reported selling food (mostly chocolate and candy) to raise money. Unlike Clarksburg-Bridgeport, where fast food outlets and convenience stores surrounded schools, in Gilmer County none of the schools had food premises nearby—a good thing when it comes to avoiding exposure to unhealthy food.
We once again made our way into restaurants, grocery stores, and convenience stores. While nearly half of the restaurants in the county were “casual dining” spots as opposed to fast food outlets (an inversion of what we’d found in Clarksburg-Bridgeport), our other findings were similar. Salads and vegetables were available at the majority of restaurants we visited, but not all. Fruit was rarely available. Nutrition information was generally absent, and not a single restaurant we visited offered healthy-eating messages on their menus. In contrast, nearly half offered “supersized” options, usually for their unhealthiest items, like soda and french fries. In grocery stores, an average of more than twelve varieties of vegetables and fifteen varieties of fruit were counted—a result that matched what we’d found in Clarksburg-Bridgeport and also coincided with research associating grocery store access with healthier diets and lower body weights. Because the county had only two large grocery stores, convenience stores here were more likely to have some vegetables and fruits, although the average was only one variety of fruit and two varieties of vegetables.
Out on the streets, we recorded our observations of all 134 street segments within Glenville. We also assessed 16 other road segments in rural Gilmer County, chosen because they fell within a quarter-mile radius of a school or large worksite. We found ourselves walking hilly terrain, at once scenic and tiring. Houses were found within a five-minute walk of schools and large worksites. Stores were also found near all worksites, and the majority of worksites had good access to restaurants. Only one was situated close to a grocery store, but three had convenience stores in the vicinity. Despite the number of destinations within walking distance, there were few sidewalks. No street segment within a quarter mile of nine of the ten largest worksites in Gilmer County had a sidewalk, and more than 40 percent of those street segments were determined to be busy.
The situation on school-zone streets was similar. Despite having housing nearby, fewer than 10 percent of street segments surrounding schools had sidewalks. Of those streets without sidewalks, nearly 40 percent in Glenville and roughly 66 percent outside of Glenville were determined to be busy—a reality than runs counter to the idea that traffic in rural areas is quiet and slow. These streets were anything but. They would not have been safe for pedestrians to use without a sidewalk, and indeed, we saw few to no pedestrians on them. Every day, opportunities for children and adults to achieve physical activity through walking were being lost. And when healthy choices are not safe choices, they’re not really choices at all.
On our third Sunday in West Virginia, as a break from work, Andrea, Michele, and I decided to go hiking at the Cedar Creek State Park. Brochures boasted of fourteen miles of hiking trails, just minutes from Glenville. It was a warm, sunny day, and the drive to the park took us through grassy, tree-lined, rolling hills. We parked in an almost empty lot and went in search of our trail. We found swimming pools, playgrounds, basketball courts, and baseball fields that were also largely empty, despite the beautiful weather. Here and there, a family picnicked around a barbecue pit, sending the smell of hamburgers and hot dogs wafting our way. Finally, we found signs indicating trails that began at a clearing and appeared to lead up into the hills. We picked one sign and began to follow the path behind it. Almost instantly, we were brought to a halt. The trail was overgrown with tall grass and dense trees. We chose another trailhead; again, within a few feet, we had to turn back. We tried a third trail. No luck. We gave up, walked back to our car, and returned to our hotel, disappointed. Our much-needed recreational exercise break was not going to happen.
Our three weeks in the field whizzed by. Before we knew it, our time in West Virginia had come to an end, and a mountain of work awaited us in Atlanta as we set about compiling our findings into a report.
On June 2, just a few weeks after we arrived home, CDC director Julie Gerberding announced our study at a press conference. The New York Times broke the story, stressing the unprecedented nature of our work: “For the first time,” health reporter Gina Kolata wrote, “the Centers for Disease Control and Prevention has sent a team of specialists into a state, West Virginia, to study an outbreak of obesity in the same way it studies an outbreak of an infectious disease.” In the days that followed, the story spread to CNN, the Associated Press, and countless other American media outlets; in the U.K., the Guardian picked it up. The Community Preventive Services Task Force asked to see our findings.
It would take months to analyze fully the data we’d collected, and to truly document why West Virginia was at the center of the obesity outbreak. But those of us who’d had “boots on the ground” already knew what to expect. Having visited schools, worksites, supermarkets, convenience stores, and restaurants, having walked the streets around these premises, having walked on Cedar Creek State Park’s unusable, overgrown trails, we knew that our data would reflect just what we had experienced: that the healthy choices that people wanted to make and the healthy choices people wanted their children to have were not easily made. In West Virginia, the deck was stacked against those who wanted to live healthier lives. Was the same true of other cities in North America and around the world? Was this the real reason behind our current—and ever-worsening—obesity epidemic?
My time as a disease detective in West Virginia helped me to see clearly what I’d suspected for a long time: our cities and workplaces and schools were inherently unhealthy. In the same way that unsanitary conditions in eighteenth-century London led to outbreaks of infectious diseases like cholera, unhealthy living conditions in twentieth- and twenty-first-century cities around the world were leading to outbreaks of non-communicable diseases like obesity and its related conditions. We put a stop to many of those infectious-disease outbreaks through the use of public health programs and initiatives. Now, the time had come to take those lessons and apply them to the prevention of our deadly NCDS.
For more than a decade now, I have been trying to do my part. In public health departments and as a consultant, I have worked with communities and organizations to bring attention to the ways that our built environment—our buildings, streets, neighborhoods, and their amenities—can better enable healthy lifestyles. After years of working in my own silo, and not finding much support for my ideas, I now have allies around the world—men and women who, like me, believe that in order to tackle obesity and its related conditions, we need to change the conversation we have been having for the last fifty years. We must recognize that we are not alone in the battle to stay fit and healthy, and that solving the problem will require a concerted, cooperative effort across many disciplines. It will require government action, community action, and action on the part of individuals who feel strongly about creating a world where we all have the ability to make healthy choices. It will mean making fundamental changes to the ways we can eat, build, move, and play. This work is underway in many cities around the world, in myriad creative and inspiring ways, and I’m excited to share some of them with you here. System-wide changes don’t come easily, or quickly. If we’re truly going to change the conversation we’ve been having about our obesity problem, the key is to get as many people talking as possible. After all, there’s strength in numbers.