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. 

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.

Read More: Medicare Will Not Cover GLP-1 Drugs for Weight Loss

The most influential of these efforts, the Framingham Heart Study, began in 1948 by recruiting ordinary residents of a Boston suburb to undergo regular examinations. The study followed more than 5,000 residents for decades, tracking their diets, habits, medical histories, and physical exams to identify the factors that predicted heart disease. Over time, the study’s reports emphasized “modifiable risk factors,” such as smoking, high blood pressure, and physical inactivity. These findings helped to enshrine the idea that chronic illness was best understood as a byproduct of individual behavior—even though the Framingham study also documented socioeconomic and environmental factors that influenced heart disease. 

Health education campaigns adopted this vocabulary, urging Americans to adopt better habits to boost their well-being. A typical mid-century health education pamphlet instructed Americans to prevent heart disease by quitting smoking, reducing fat intake, and exercising regularly. This advice sidelined environmental constraints like housing and work conditions, which also influenced people’s health. The Cold War political culture helped shape the new epidemiology and reinforced its emphasis on Americans getting in shape. Presidents and policymakers promoted bodily discipline as a civic virtue, warning of a nation weakened by sedentary habits and “softness.” One widely distributed 1960s filmstrip, The Smoking Machine, showed a clear plastic lung turning black as a motor pumped cigarette smoke into it—an iconic demonstration that taught children that disease was the direct result of individual behavior. The President’s Council on Physical Fitness cast exercise as both a healthy behavior and a patriotic obligation, linking the disciplined body to the national strength necessary to defeat the Soviet Union. 

Taking their cues from the political climate, public health agencies adopted this way of thinking as well. By the 1970s, the Department of Health, Education, and Welfare’s Healthy People initiative framed chronic disease as a problem that could be solved by Americans modifying their personal habits, treating lifestyle change as the central strategy for prevention. Emphasizing personal behavior allowed public health agencies to promote action without confronting powerful economic interests or demanding large-scale economic redistribution.

Corporate strategy intensified this shift. Facing mounting evidence that cigarette smoking caused cancer and heart disease, tobacco companies developed public-relations campaigns that stressed “freedom of choice” and individual responsibility. Litigation revealed that industry leaders worked to redirect attention away from marketing practices, product design, and secondhand smoke. By the late 1970s, major companies were explicitly framing smoking as a matter of personal choice to deflect regulatory pressure and shift blame for disease onto consumers. Food and beverage companies later adopted similar strategies as consumption of sugary content began to draw greater scrutiny. 

The focus of public health agencies on individual behavior only intensified as the country moved rightward in the 1980s. In an era defined by President Ronald Reagan’s emphasis on small government and deregulation, it was far less controversial—and far more politically feasible—to target unhealthy behaviors like smoking than to implement and defend large-scale structural reforms such as regulating work schedules, enforcing environmental protections, or addressing residential segregation. Policymakers, who championed small government and aimed to reduce welfare spending, increasingly interpreted ailments and struggles, whether economic or physical, as failures of personal effort and responsibility rather than reflections of broader forces beyond a person’s control. Popular rhetoric cast poverty and dependence as moral failings, exemplified by stereotypes like the “welfare queen,” which portrayed recipients of public assistance as irresponsible and undeserving (and thus deserving of reduced, or no, benefits). These narratives reinforced the idea that social problems—including poor health—stemmed from personal behavior rather than structural inequality. Such efforts cost less, which mattered in an era of budget constraints, and didn’t provoke the same political uproar. 

The creation of the CDC’s Behavioral Risk Factor Surveillance System, which systematically tracked self-reported behaviors like smoking, diet, and exercise, cemented this orientation by making self-reported lifestyle factors the backbone of national chronic-disease surveillance.

Read More: How Bureaucracy and Budgets Shape American Medical Research

In 1996, this conservative logic culminated in a seminal welfare reform law, which tied government aid to behavioral expectations, most notably having a job. In the decades to come, this logic spilled over into public health programs. Republicans embraced proposals to impose work requirements in Medicaid, which treated access to medical care as contingent on demonstrating “responsible” behavior. President Trump’s “Big Beautiful Bill” imposed such a requirement nationally, despite evidence showing that in Arkansas — the one state that implemented a Medicaid work requirement long enough for it to be studied — it produced significant coverage losses without gains in employment or health.

Obesity has become one of the clearest arenas in which this ideology took hold. Public-facing materials and media narratives frequently frame weight as evidence of a lack of willpower to resist fatty and sugary foods — despite evidence to the contrary.  Scholarly research highlights how neighborhood design, food availability, and economic constraints shape body weight patterns far more than individual preferences alone. Global studies have similarly found that obesity is more prevalent in places marked by economic inequality, suggesting that cultural and environment factors, rather than individual choices, play a greater role in weight outcomes. Together, these findings indicate that obesity follows predictable social and economic patterns, rather than arising primarily from individual failures of self-control.

Yet despite overwhelming evidence, popular culture and public health messaging continue to insist that people simply need to “eat less and move more.” Television segments and health columns routinely advised Americans to “burn more calories than you consume,” reinforcing the idea that weight is fundamentally about personal effort. The durability of this message reflects decades of scientific findings, political pressure, and corporate influence that have repeatedly encouraged Americans to see health as a private responsibility. In reality, however, many of the most effective public health innovations in American history—clean water systems, better housing, workplace regulation—succeeded precisely because they addressed the environments in which people lived and worked. Contemporary research continues to show that social and economic conditions exert a major, often decisive influence on morbidity and mortality—beyond what individual behavior alone can explain. 

Which brings us back to the debate over GLP-1s. These drugs have become a cultural flashpoint not simply because they are expensive or transformative, but because they challenge a deeply rooted American conviction: that illness signals personal failure and health reflects virtue. This belief has endured despite a long history of public health innovations that suggest otherwise. While individual responsibility campaigns have raised awareness, they have produced uneven and often modest improvements in the health of Americans whereas structural interventions that change the conditions in which people live have demonstrated far more success. 

Zachary W. Schulz, PhD, EdS, MPH is a historian of public health and a senior lecturer at Auburn University.

Made by History takes readers beyond the headlines with articles written and edited by professional historians. Learn more about Made by History at TIME here. Opinions expressed do not necessarily reflect the views of TIME editors.