Where Health Actually Comes From

I’ve spent more than 25 years in emergency medicine. It’s been a privilege to care for people in moments that matter—when something has already gone wrong.

Over time, the work changes you. You begin to see patterns.

A heart attack, a shooting, a diabetic crisis, a mental health emergency—these don’t come out of nowhere. They follow a trajectory. And from the bedside, you can start to trace that trajectory backward.

Upstream.

What you find is consistent. These events are rarely random. They are shaped by the conditions people live in—social, environmental, economic. Stress. Isolation. Stability. Purpose.  Opportunities for movement. Access to real food. The quality of the air, water, and land around them. The presence or absence of community.

We know this. In public health, it’s well established that these conditions—also known as the social determinants of health—play a far greater role in overall health than what happens in clinical care. Medicine is essential, but it is downstream. By the time someone arrives in the emergency department, the trajectory is already well underway.

If you want to change outcomes in a durable way, you have to change the conditions that shape that trajectory.

But here is the honest reckoning.

The system we work in is not designed to do that.

As outlined in a recent perspective in the New England Journal of Medicine, the U.S. health care system remains structurally oriented toward treating illness rather than sustaining health. Hospitals and physicians are financially dependent on volume—on people being sick enough to require care. Prevention reduces utilization, and in many cases, revenue.

Even well-intentioned efforts to move upstream—home-based care, digital health, retail clinics—struggle to sustain themselves. Not because the ideas are wrong, but because the incentives are misaligned. Health is difficult to define, measure, and monetize. It does not fit neatly into billable units.

And perhaps most importantly, the system is not built to deliver the very things that matter most: food, environment, social connection, and daily conditions.

Health, in other words, does not come from the health system.

It comes from outside of it.

About a decade ago, I saw this clearly in another context—firearn-related injuries. Through community-based efforts, relatively small interventions could interrupt a chain of events and prevent harm. Not through force or control, but through connection, awareness, and people willing to step in. It revealed something important: when people recognize a problem that matters, they show up.

That same principle applies more broadly.

If we want to change the trajectory of chronic disease, mental health, and social breakdown, we have to invest further upstream—at the level of environment and everyday life.

For me, that path led to the land.

In working landscapes—farms, forests, and rural communities—you find a different set of conditions. Food is grown close to where it’s eaten. Movement is part of the day. Time follows natural rhythms. People are connected to each other and to place through shared work and shared purpose. The environment is not separate from life—it is life.

This is not theoretical. It is practical, visible, and already in motion.

Regenerative, organic agriculture, in particular, makes this explicit. It is built on the understanding that soil health drives plant health, which drives animal health, which ultimately shapes human health. The same systems that restore land also restore function—ecological and human.

What began as a personal commitment to farming has evolved into something broader. Through farm-based hospitality—whether agritourism, farm stays, community supported agriculture (CSA), and market gardens, among others—these landscapes can be shared. Not as curated experiences or staged wellness, but as real, working systems that people can step into.

This is the foundation of Agrarian Health.

It is not a program or a prescription. It is an applied, place-based approach that reconnects what has been separated—health, environment, food, and community. It invites participation in the very conditions that support well-being.

People come for many reasons—to get away, to spend time outdoors, to be with family, to try something new. What they often find is something more fundamental. Steadier energy. Better sleep. Clearer thinking. A sense of connection that is hard to replicate elsewhere.

These are not isolated outcomes. They reflect a shift in conditions.

And when conditions shift, trajectories change.

This is where the work is going.

In the coming months, we will begin to more clearly articulate the health and wellness dimensions of agrarian life—grounded in both evidence and lived experience. This includes case examples from our own farm and others, practical guidance for agritourism operators who are already doing this work (often without naming it), and simple frameworks to help guests understand and apply what they experience.

The goal is straightforward.

To make visible what is already working.
To describe it clearly and honestly.
And to support the people and places already creating the conditions for health.

After a quarter century in emergency medicine, the direction is clear.

If we want different outcomes, we cannot rely on the system that depends on illness to sustain itself.

We have to build and invest in systems that produce health.

And those systems already exist.

They are on the land.

David M. Cutler, PhD; Robert S. Huckman, PhD.Has Corporatization Met Its Match? The Challenge of Making Money by Keeping People Healthy. N Engl J Med. 2025;393(22):2177–2179. doi:10.1056/NEJMp2513434.