Philip Alcabes discusses myths of health, disease and risk.

Anti-Tobacco Crusaders

It’s hard to understand why the public health industry is so irrational about tobacco use.  Yes, it’s dangerous  to inhale the fumes of burning tobacco.  Smoking can be very bad for people.  But why vilify tobacco use in all its forms?

The anti-tobacco crusade is a modern-day version of Revivalist religious fervor.  It sure isn’t science.  And it isn’t about protecting people’s health.

The CDC estimates that 442,000 Americans die from tobacco smoking each year.  These estimates are slippery; they’re based on a fairly loose definition of what it means to die “from” a behavior — but let’s agree that a lot of people die sooner than they otherwise would because they smoke cigarettes.

Alternative ways of self-administering nicotine allow users to avoid the disastrously harmful drug-delivery device, the cigarette.  You’d think that Big Public Health, 45 years into a campaign to get people to stop smoking, would be promoting all sorts of safe methods of nicotine delivery.

That’s not what happens.  Instead, the industry pours anathema on light cigarettes, smokeless tobacco, and other safer-than-cigarettes products.

The latest sermon is an article in this month’s The Nation’s Health — the newsletter of the American Public Health Association (APHA, which has turned into the High Synod of Public Health Religion).  The article  claims that “New Types of Smokeless Tobacco Present Growing Risks for Youth.”

The title is a double rhetorical turn now (alas) typical of APHA:  (1) your kids are going to die, and (2) the “risk” to them is increasing.  The piece would seem silly if the author, named Kim Krisberg, weren’t so serious.  After all, it isn’t kids who die from smoking, and the risk of smoking-related death isn’t increasing at all.  But we’re not in the realm of truth here.

Since Big Public Health isn’t dealing in truth when it comes to tobacco, evidence isn’t part of the story.   The head of the Campaign for Tobacco-Free Kids can say “the time to stop the spread of dangerous products is before they become the fad of today,” insouciantly sidestepping the fact that smokeless tobacco products aren’t dangerous.  Brad Rodu’s invaluable website Tobacco Truth explains — see Brad’s June 16th post, for instance.  Or go to this page at the excellent resource TobaccoHarmReduction, or see this article published in Cancer Epidemiology, Biomarkers & Prevention in 2004.

The public health industry’s animus for tobacco leads it to label as harmful something that is really a boon to public health — the increasing use of products that provide nicotine without burning tobacco.  Surely it’s better to have people chewing nicotine-containing products that won’t harm them than to allow them to continue smoking tobacco in order to get a nicotine dose.

Moralistic fervor makes you stupid.  Stupid enough to write, as two physicians with FDA’s Center for Tobacco Products did,

As state and local communities across the United States adopt indoor clean-air laws that restrict smoking in public areas and workplaces, the tobacco industry seems increasingly focused on the development and introduction of novel smokeless tobacco products

… as if the tobacco industry were magically making Americans who would otherwise stop smoking suddenly crave smokeless tobacco — and as if that would be bad for them.  Drs. Deyton and Cruz, you should know better.

But Matthew Myer with Tobacco-Free Kids isn’t unintelligent.  Nor, I assume, are Deyton and Cruz.  And I can’t imagine they really want people to suffer.

Still, do they really think that safe non-smoked tobacco products are going to bewitch our kids?  Do they believe that apocalypse comes in a package of smokeless tobacco?

Are they just so obsessed with battling tobacco companies that they’ve lost sight of the aim of public health, i.e., to reduce suffering?

Or is it simpler?  Has the public health industry’s big-money anti-tobacco campaign allowed too many people to make too good a living by saying stupid things about tobacco?

The cigarette manufacturers have been scurrilous, dastardly, and sometimes appallingly inured to the misery and death their products have hastened.  Maybe they deserve the Myerses of the world.

But the public health industry could be a lot more focused on helping people to live less painful lives, and less obsessed with its private demons.

As Carl V. Phillips suggests in a post this week, the FDA will have to break with the public health industry’s moralism if people who use nicotine are going to protect themselves from cigarettes.

If the FDA can’t overcome Big Public Health’s obsession with satanic tobacco rituals, re-introduce truth into the discussion, and re-focus on making real people’s lives less miserable, the zealots are going to turn stupidity into bad policy.

By Philip Alcabes | August 3rd, 2010 | Categories: Behavior, Health Professions, Risk, Uncategorized, public health, science, tobacco | Tags: , , , | Comments Off

Media Culture: Beyond Fat and Salt?

Over at Media, Culture & Health, Steven Gorelick notes that a story on salt and the food industry, which appeared on page A1 of the print NY Times on Sunday, would not have made the front page in the past.

What has changed?  How does the story of wrangling over the sodium content of American food merit space in the main news sections of the most influential media — even the front pages of the NY Times or LA Times?

1.  One answer is that health occupies much of the American conversation today.  A visitor from another planet watching our TV news shows or reading the main newspapers would have to be forgiven for thinking that Americans are dying from a multitude of irrepressible disease threats.  We can’t seem to stop talking about how to improve our health.

(In fact, as Michael Haines notes at the Economic History Association website, U.S. life expectancy almost doubled between 1850 and 1960, from 39.5 years to 70.7 years; since then it has increased slowly, and is now estimated to be about 78.2 years.  In other words, health wasn’t a matter of news much during the time when longevity was improving dramatically, in the late 19th century and first half of the 20th.  By the time health became a cultural preoccupation, the majority of Americans were living well past middle age.)

2.  Another answer, perhaps more important is that when we talk about health today we mean personal responsibility.

When I began studying epidemiology, in the late 1970s, public health essentially meant disease control.  Yes, lip service was paid to so-called health promotion — much was made of the World Health Organization’s definition of health, promulgated in 1946:

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

But no metric for complete well-being was widely recognized.  And the usual epidemiologic measures of incidence and mortality rates, life expectancy, and so forth seemed to work just fine as ways of understanding why some groups of people lived longer and more capable lives, while others lived miserably and died young.

Sometime since then, the health sector, including public health, has turned to individual responsibility as the key to well-being.

If each of us is responsible for his or her own health, then it’s our own fault if we get sick.  Naturally, advice abounds:  buckle up, use a condom, eat less fat, know your cholesterol level, wash your hands, use mosquito repellent containing DEET, wear sunblock, eat fresh fruit and vegetables every day, lower your stress.

The advice adds up to this:  know your limits.  Federally sponsored research tells us that self-control is ontagious.

The personal-responsibility view of health says, “control your appetites.”

3.  But let’s think about another change:  more people are concerned about the American diet.  As noted last week, the food movement has given us ways to think about eating that go beyond the tiresome story of obesity and hypertension — Beyond Fat and Salt, you could say.

Of course, the main media outlets still tell the food story in Fat-and-Salt language, as the news articles in the NY Times, LA Times, and others show.  It’s the food industry vs. the foodies, or the food industry vs. public health, or the food industry and public health vs. appetites — anyway, somebody against somebody in the name of health.

The media aren’t quite past obesity and hypertension yet.  But as the culture moves beyond obsessive self-inspection in the name of health, no doubt media will, too.


By Philip Alcabes | June 3rd, 2010 | Categories: Behavior, Disease, Health Professions, Narratives, News, Uncategorized, obesity, public health | Tags: , , , , , , , | 2 comments

Putting Obesity in Perspective

Michael Pollan’s essay in this week’s NY Review of Books offers a framework for looking at modern food and eating.  If public health advocates took Pollan’s perspective, the vitriol of their anti-obesity crusade could turn into a force for real social reform.

Reviewing five books on what he calls the “food movements,” Pollan notes the widespread discontent with contemporary industrialized food production (I’ll call this “American eating,” although its dominance is increasing around the world).  And he suggests that its common theme is cultural discomfort. The food movement, Pollan argues, has “set out to foster new forms of civil society”:

It makes sense that food and farming should become a locus of attention for Americans disenchanted with consumer capitalism.  Food is the place in daily life where corporatization can be most vividly felt…  The corporatization of something as basic and intimate as eating is, for many of us today, a good place to draw the line.

This is a refreshing insight.  It’s thankfully broad, taking  the focus away from health, and therefore from the anti-obesity crusade and the “toxic food environment” view promoted by health advocates.

But Pollan’s perspective is especially refreshing because it renews the conversation about our private lives — particularly the extent to which we’ve ceded our innermost values to the demands of corporate profit and government policies.  And those demands, as Marion Nestle often points out (recently here), are generally linked.

Pollan reminds us that our innermost values are literally innermost:  they have to do with what goes into our stomachs.

I’ve already stated my argument that the anti-obesity crusade is really about control, not health (see here and here).   The crusaders do cite “public health” as a rationale for the war against obesity.  But when they describe what’s wrong, they do so in terms that are sometimes medical (diabetes, hypertension), sometimes technical (serving sizes, calorie counts, the infamous toxic food environment), and sometimes medieval (gluttony, laziness).  Their inability to articulate the source of the problem is a signal that they’re sure something is out of control but unsure exactly what.

The public health approach to obesity is a failure.  It doesn’t let us talk about what needs to be reformed.  And it’s often allied with efforts to make sure the poor stay poor — even though wealth inequality is surely part of the problem in the first place.  The public health industry’s demands for additional regressive taxation in the form of increased “fat” taxes on sugary beverages or high-calorie foods reveal its preference for the status quo.  Make the poor pay more for their soda and fast food; that will make them think twice about supporting industries that are making us fat.

Even well-meaning public health professionals who advocate government intervention against low-price-but-low-nutrition food  as a way of curtailing obesity ignore the central role of food and eating to liberty and happiness — they’re interested primarily in how many additional years of life (however unhappy) could be purchased by trading in the fries in favor of broccoli.  Or, worse, they’re interested only in the dollar costs to taxpayers — in terms of hypertension and heart disease — of tolerating obesity.

Pollan, today’s most thoughtful and insightful philosopher on the subject of food and eating, offers a more satisfying view.  Sure, you may want to change American eating because you think obesity is bad for people’s health.   But you might want to change eating simply because the food scene is distressing, because it crystallizes and exemplifies the many ways that we give over our private (innermost!) moral decisions to the influences of corporate/consumerist thinking.  You might want to change it because, as Pollan reminds us (in regard to a new book by Janet Flammang), the dominance of American statecraft by corporations allows the preparation of food to be relegated to the least valued, least powerful, and lowest paid workers.  You might want food to taste better — valuing pleasure over longevity.

With Pollan’s broad view, you  don’t have to join the anti-obesity crusade.  You don’t have to speak the technical language of risk.  The common language of freedom, desire, and pleasure will do.

By Philip Alcabes | May 26th, 2010 | Categories: Behavior, Health Professions, Narratives, Risk, Uncategorized, epidemics, obesity, public health | Tags: , , , , , , | 2 comments

New Year’s Wishes for Public Health

May 2010 be the year when health officials return to the business of alleviating suffering and stop promoting panic. (Don’t miss Nathalie Rothschild’s “Ten Years of Fear” in Spiked!’s Farewell to the Noughties, recounting the hyped-up panics of the ’00s — from the Y2K bug to swine flu.)

May CDC become a force for real public health, not an advocate for the risk-avoidance canard.  May the new director, Dr. Frieden, stop favoring pharmaceutical companies’ profit making through expansion of immunization.  And may he direct the agency to begin to address legitimate public needs, like sound answers about vaccines and autism, and clear communication about what is — and isn’t — dangerous about obesity.

May WHO officials stop playing with the pandemic threat barometer.  May WHO begin demanding that the world’s wealthy countries devote at least the same resources to stopping diarrheal diseases, malaria, and TB as they do to dealing with high-news-value problems like new strains of flu.   Diarrheal illness kills as many children in Africa and Asia in any given week as the 2009 swine flu killed Americans in eight months.  So does malaria.   Direct policy, and money, toward sanitation, pure water free of parasites, adequate treatment of TB, mosquito control, and prevention of other causes of heavy mortality in the developing world — not just flu strains that threaten North America, Europe, and Japan.

May public health professionals lose their obsessions with bad habits. May the public health profession return to the problem of ensuring basic rights — access to sufficient food, clean water, decent housing, good education, a livable wage, and adequate child care — and ease up on its moralistic obsessions with nicotine and overeating (for recent examples of the preoccupation with tobacco, see this article or this one (abstracts here; subscription needed for full articles) in recent issues of the American Journal of Public Health).

May science be what Joanne Manaster does at her incomparable website: looking at the world with wonder, asking without dogmatic preconceptions how it works, and accepting that its irrepressible quirkiness makes it impossible to know the world perfectly.  May science not be the crystal-ball-gazing thing whose so-called “scientific” forecasts are really doomsday scenes worthy of the medieval Church — predictions of liquefied icecaps and rising seas,  hundreds of millions of deaths in a flu pandemic, or catastrophic plagues sparked by people with engineered smallpox virus.  There are plenty of reasons to be concerned about both the environment and disease outbreaks based on sound here-and-now observations; leave the forecasts of Apocalypse to the clergy, who know how to handle dread.

A new year’s wish (from the valedictory exhortation in Tony Kushner’s Angels in America):  “More life!”

By Philip Alcabes | January 4th, 2010 | Categories: Behavior, Disease, Health Professions, Myths, News, Outbreaks, Risk, epidemics, obesity, public health | Tags: , , , , , , , , , , , , , | 1 comment

The Anti-Obesity Crusade Invades Academia

The Chronicle of Higher Education reports that students at Lincoln U. in Pennsylvania can now be required to take a physical exercise course (“Fitness for Life”) if they have a body-mass index above 30.  The chairman of the college’s Department of Health, Physical Education, and Recreation pointed out that he sees a responsibility to address the “obesity epidemic.”

Nutty, but not so terrible, perhaps.  The policy is a transparent attempt by a not-so-wealthy university to seem au courant and curry favor with donors, who might like the idea that the school is addressing obesity — which the public health industry keeps insisting is a terrible problem facing young people.

Really, the obese-student policy at Lincoln doesn’t demand much.  Some students have to work out for a few hours a week (it’s a 1-credit course).  Not how they want to spend their time, probably pointless in terms of their health, but not the end of the world.

But pay attention to the commentary.

The director of another university’s center on higher-education law and policy voices concern — not over Lincoln’s feeble gesture at controlling fatness , but over medical confidentiality.  “Being put in a class with other ‘at-risk’ BMI’s walks a little close to disclosure,” he told the Chronicle.

The implication here is that obesity is an illness, and therefore only a physician should be allowed to know that you have it.  Certainly, your classmates shouldn’t.

How can obesity, of all things, be thought of as a secret that would only be revealed if you got into gym shorts and showed up on the treadmill in the fat-students’ class?

There’s a clue in the use of the term “at risk”:  obesity is like sleeping around without using condoms, driving drunk, or smoking near your kids  — it’s supposed to be both dangerous and shameful.  You would only admit being “at risk” to your doctor (who would, we have to assume, dutifully dissuade you from following your naughty instincts).

At the NYT blog The Choice, Rebecca Ruiz notes that the Lincoln faculty will be discussing the problem tomorrow.  So far, there’s been plenty of skepticism there, but a few defenders of the fat-class policy.  And most of the comments responding to Ruiz have been supportive of the idea that a university might require physical exercise.

What isn’t getting mentioned is race.  Is the policy popular because Lincoln is one of only two HBCUs in Pennsylvania, and some of the much-discussed “adverse outcomes” of obesity are conditions that are common among African Americans?  Do people feel  relieved that a predominantly African-American university is addressing a problem that seems somehow racial?  Do we feel reassured that a college that  doesn’t serve America’s traditional wealthy elite is taking on a problem that seems to be a threat to the elite — and a threat that seems born of the bad habits of the poor, especially the dark-and-poor?

Obesity is more common among people who identify themselves as African Americans — even at colleges, as a recently published study showed.  Here, and worldwide, obesity is mostly a problem of poverty.

Doesn’t obesity’s taint stem, at least partly, from the way it reminds Americans of poor people — and the dark-skinned poor in particular?

By Philip Alcabes | December 3rd, 2009 | Categories: Behavior, Risk, epidemics, obesity, public health | Tags: , , , , , , | Comments Off

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