The debate over whether insurers should pay for GLP-1 drugs like Ozempic and Wegovy has revived a familiar American argument about why people get sick. Some commentators have insisted that the powerful weight-loss drugs are “shortcuts” for people unwilling to exercise greater self-control, a concern echoed in coverage noting that experts worry too many patients may be trying GLP-1s as a shortcut instead of improving their diet and exercise. Others disagree, countering that decades of research shows that income, food access, neighborhood design, and chronic stress shape body weight. Beneath these disputes lies a deeper question: Is health primarily a matter of personal discipline, or a byproduct of the social and economic conditions in which people live?

This debate has a long history. For much of the early 20th century, U.S. public health officials understood disease as a collective problem. Federal and municipal investigations linked infant mortality and other diseases to contaminated water, overcrowded housing, and inadequate sanitation, rather than to individual failings. Local health departments inspected milk and enforced housing codes because evidence showed that contamination and crowding—not household virtue—drove disease. In response, cities expanded sewer networks and installed municipal water filtration systems, treating sanitation as a public responsibility rather than a private household matter.

This consensus, however, began to fray in the late 1940s and 1950s, as a confluence of factors drove public health officials, politicians, and journalists to focus increasingly on how individual behaviors contributed to chronic disease. The result was a profound reframing of illness: disease increasingly appeared to be the outcome of poor personal choices rather than the product of social conditions beyond any single individual’s control. This new understanding came about because individual responsibility proved easier to measure, govern, and moralize. But the reality was that collective solutions consistently continued to deliver the greatest health gains. 

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To some degree, the U.S. began to move away from understanding illness and disease as a collective problem, because social interventions were almost too successful. In the first half of the 20th century, innovations—including improved sanitation and the advent of new vaccines and antibiotics—led to infectious disease mortality plummeting. Between 1900 and 1950, U.S. deaths from major infectious killers fell by more than 90%. With the great infectious threats receding, researchers turned toward chronic disease. Epidemiologists quickly identified correlations between behaviors, including smoking, diet, and physical activity, and conditions like heart disease and cancer, helping to launch what later historians called “risk factor” epidemiology.

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