In How Not to Die (Too Soon), Professor Devi Sridhar comprehensively debunks the ‘lie’ of health as an individual responsibility, and makes the case that policy – not personal choice – shapes life expectancy. She argues that where you live matters, and that the expected behaviours, determined by government action or inaction within this context, can shape not just your life, but also your quality of life.
Sridhar is clear: we already know what works. “We know from scientific studies and decades of public health research not only how to increase life expectancy but also how to maintain quality of life.”
Why can’t we all live to be 100?
Sridhar uses the age of 100 as the collective target for life expectancy and explores reasons why this is both attainable and unattainable worldwide. She comprehensively highlights nine of the most important risk factors that affect our ability to live longer and challenges us to recognise the bad actors, companies and individuals that are standing in our way.
“We have been focusing on the wrong thing: namely, we have been focusing on ourselves. This means looking at government policies that promote long lives … nine of the most important risk factors affecting healthy life expectancy in all countries: physical activity, diet, smoking, mental health, gun violence, safe roads and transport, clean water, clean air and access to quality health care.”
What’s standing in the way
Again and again Sridhar makes the point that the measures needed to live longer are well known and that societal accountability is the crux of the problem.
“We know how to prevent millions of unnecessary early deaths around the world, both in developing countries and closer to home.”
If we know how to prevent millions of premature deaths, the question becomes why these lives are categorised as expendable, and who has made the decision that some lives – in most cases, the wealthiest – more valuable and need more protection than others.
It would have been too easy for this book to turn into a polemical rant about obstructionist capitalists intent on putting growth over human suffering. Instead, Sridhar effectively sidesteps this trap and offers examples of countries and communities that have successfully changed, adapted and evolved to better protect all their citizens. Her goal is clear: “My aim with this book is to show you that we know what works in solving the major health challenges.”
“This is a book about how to live longer”
Sridhar also makes it emphatically clear: “This is not a book about how to die. This is a book about how to live longer”. There is a strong focus on family and the power of human relationships that echoes through the book; aspects of life that can enhance our human experience. She quotes her ‘Nani’, who recently celebrated her 90th birthday, whose mindset is: “It’s not about how to die. It’s about how to live”.
It is important to appreciate the accidents of our lives because, as she writes, “life is special because it is finite”. Therefore, a longer lifespan is possible, attainable, and should be a birthright for all. Sridhar reminds us that in the mid-19th century, a life expectancy of 40 was not considered ‘midlife’ or ‘middle-aged’. She celebrates how far we have come since then and questions why extending a healthy life should not be the new expectation. “In 1841, life expectancy at birth was roughly forty years old…Back then, forty wasn’t mid-life: it was life.”
Of course, the nine risk factors that Sridhar explores in the text, were not as prevalent in the mid-19th century, although avoiding cholera outbreaks by not drinking unsafe water, discovered in the UK through the efforts of John Snow, is something still experienced by millions around the world today.
Designing cities and systems for health
Of the many global examples Sridhar cites, the Netherlands is highlighted as an example where ‘it wasn’t always like this’, but rather where cities have been designed and structured to prioritise health. So, if examples exist, it is logical to understand that they can be emulated in other cities and countries.
Paris, in France, has also set itself the goal of making citizens’ health an integral part of daily life, through its creation of ‘15-minute cities’ – whereby “a city should be designed so that most of people’s daily errands, work, education and life can be carried out within fifteen minutes (by foot or bicycle) from their home”.
Nothing inherently unusual or controversial there, if a healthier future is the goal. “The way to shift physical activity at a population level, as shown by Amsterdam and Paris, is to build it into daily life so that it becomes practical, invisible, free (or cheap) and social.”
But implementing health-first planning comes with political resistance. Unfortunately, populists have gained traction in recent years by labelling these cities as places where you have only ‘15 minutes of freedom’ and that these health measures are ‘Stalinist’. Sridhar highlights some of the obstacles and challenges faced by countries trying to build healthier communities for their citizens in the long term; that these are held back by political interests and vested interests seeking to protect their profits and cause division.
Policy, not personal willpower
We are victims of circumstance in terms of geography and economic systems. Some of us can move to avoid the worst effects and thus live longer, healthier lives, but this is not an option for everyone. Although some risk factors are within our control, Sridhar turns to the most obvious one that we have no control over, whether we live in Switzerland, India, South Africa or the UK – the quality of our air and the impact of air pollution.
Dr Maria Neira of The World Health Organization says, “The problem is that when you’re a citizen, you can’t choose the air you’re breathing. You breathe whatever is available”. The need for clean air to enable people to enjoy healthier lives didn’t use to be a political football or a partisan issue. Until recently, when populists branded clean air ‘anti-car’, and once again prioritised industrial capitalist profits over public health, it was viewed as a public health issue across the UK. “The backlash against clean-air measures is baffling: we all live longer with cleaner air, and the issues should have widespread appeal.”
Early deaths worldwide could also be prevented by effectively changing and adapting to a more physically active lifestyles. “The World Health Organization estimates that four to five million deaths per year could be averted if the global population were more physically active.”
Sridhar argues convincingly: “Just telling people to move doesn’t work if they can’t implement this advice within their daily life and routine”.
A blueprint for hopeful, healthy lives
How Not to Die (Too Soon), then, outlines a blueprint – a hopeful pathway to a healthier world. A path that shows and challenges why the needs of the many don’t outweigh the needs of the few, or the one. As demonstrated throughout the book, countries around the world have identified the risk factors for their own populations and then enacted long-term solutions which change the attitudes and behaviours permanently for the better. Governments can be powerful instruments of good that leave no one behind. “That’s the politics of hope: we must imagine a healthier world and take the public policy steps towards it.”
All that remains is to change the political will and to make health a priority, in order to improve life for all within a society. After all, “Life isn’t about not dying too soon. It’s about enjoying and being happy with living”.
