Philip Alcabes discusses myths of health, disease and risk.

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

Obesity and Public Health Control

This month’s American Journal of Public Health brings us a primer (abstract here; subscription required for full text), written by lawyers supported by the Robert Wood Johnson Foundation, teaching “policymakers to avoid potential constitutional problems in the formation of obesity prevention policy.”

The article isn’t exactly a Steal This Book for the anti-obesity crusaders, but the authors’ stated aim is to help those crusaders skirt legal challenges to statutes that might, for instance, ban fast foods or require the posting of accurate calorie counts on restaurant menus:  “This primer is meant not to deter obesity prevention efforts but to foster them,” the authors adumbrate.

Of course, the anti-obesity crusade is well on its way to using the law to tighten the control of behavior already.  And the failure of restaurant calorie counts to show any effect on eating patterns isn’t dampening enthusiasm, it seems.

Brian Elbel of NYU and colleagues just reported in Health Affairs that the calorie counts now posted by law in New York (another piece of legislation backed by our bluenose mayor) don’t affect how much people eat,  based on a study of over a thousand New Yorkers from minority neighborhoods (abstract here, full article here).  At Freakonomics, Stephen Dubner surmises that this sort of program only helps people “who are already the most vigilant about their health and well-being.”  But it’s hard to find anyone in public health who is opposed.

They should be.   The public health industry, which likes to claim its main interest is human dignity, should be lobbying for less regulation of human appetites, not more.

But public health is often the pre-eminent paradigm of control in our society. Rename the acts or traits you find morally repugnant as diseases, and you can hand them to the health sector for management.   Once you say you’ve got an epidemic on your hands, you can count on the public health industry to respond.  Alcoholism, addiction, smoking, obesity, social anxiety… there seems to be a big supply of epidemics that used to be moral offenses or threats to the social order and are now opportunities for your doctor or your health commissioner — not your clergyman — to tell you how to act.

The neat thing about the control exercised through public health is that you never have to sermonize, read Bible verses, or prophesy Apocalypse.  The rhetoric of risk is a lot easier for the self-professed progressives in public health to swallow than religious sermonizing would be.  Even when the sermon and the risk rhetoric have the identical goal: wiping out the moral offense.

From Junkfood Science, we learn that

Employers will now perform random tests of employees for evidence that they’ve smoked outside of work and will weigh employees in the workplace and report their BMIs to the state. Employees deemed noncompliant with the State Health Plan’s employer wellness initiative, will pay one-third-more for health insurance. Employers believed that eliminating smokers and fat people would lower health costs.

And from WSJ Health Blog, that the CEO of pharmaceutical corporation Schering-Plough agreed (at a meeting at the Cleveland Clinic) that people with unhealthy behavior should pay more for health insurance.  Sure — you certainly wouldn’t want the wealthy to pay more.

That’s not the only problem with the public health industry’s vigorous embrace of behavioral control, but it’s a big one.  Start classifying people based on how they behave, and you begin discriminating against the ones who don’t act right.  But the ones who you think don’t act right are almost always the ones society was already discriminating against — the poor, most of all.

And even when the poor aren’t getting shafted in the crusade against the unhealthy, inquiry about how a just society should work is going down the tubes.  The profound moral-philosophical questions of what is the right way to live a life, the right way to raise children, the nature of liberty, and so forth, are surrendered in the public health paradigm – replaced with the simple dichotomy:  healthy vs. not-healthy.



By Philip Alcabes | October 11th, 2009 | Categories: Behavior, Disease, Health Professions, Physicians, Risk, Uncategorized, epidemics, obesity, public health | Tags: , , , , , , | Comments Off

America, Free of Risk: Taxing Soda

The possibility of a tax on sugar-sweetened beverages has been re-awakened, sparked by this week’s New England Journal of Medicine article, written by some prominent researchers and officials.  It’s the latest instance in the long battle to turn the conduct of private American lives over to the care of larger forces — Big Science and Big Public Health.  Another step toward the public health vision of risk-free America.  Another step away from the relief of suffering in favor of meddling with people’s choices.

The NEJM paper argues that there would be health benefits of a tax on sugar-sweetened drinks — preferably to take the form of about a penny’s worth of excise tax levied per fluid ounce for any beverage containing “added caloric sweetener” (possibly to be defined as more than 1 g of sugar per 30 ml of beverage).

There’s much to be learned by the response.  The NY Times article, in its Business section Wednesday, was titled “Proposed Tax on Sugary Beverages Debated” but was generally slanted strongly in favor of the proposal.  If you read only the Times, you would think that objections to the tax come only from industry, which obviously has an economic interest in keeping sales of soda and sport drinks up by keeping the price down.

Shirley S. Wang at yesterday’s WSJ Health Blog adds some insight.  She points out that a 2-liter bottle of soda subject to the proposed tax, assuming the tax is entirely passed along to consumers in the form of higher prices, would still be much cheaper than a half-gallon of orange juice.

James Knickman of the NY State Health Foundation, writing in the NY Daily News last week, acknowledged that a soda tax would be essentially regressive, affecting the poor more powerfully than it does the wealthy.  He urges that

To counteract the soda tax’s regressive nature, revenue generated from the tax should go to health-related programs that benefit the poor – essentially putting the money back into their pockets. The revenue could be used for myriad initiatives, including subsidies for federal health reform – which is estimated to cost $1 trillion over the next 10 years – subsidies of fresh fruits and vegetables and other healthy foods in low-income community grocery stores, and food stamp increases for the purchase of fresh fruit and vegetables.

Knickman gets at one of the main purposes of a tax like this:  to get the poor to pay more of the costs of doing business.

But what isn’t being discussed, it seems, is the underlying logic.

First, there’s the assumption that obesity is uniformly and intensely bad.  The NEJM article begins with the statement “The consumption of sugar-sweetened beverages has been linked to risks for obesity, diabetes, and heart disease,” citing three articles — two of them authored, in part, by the same men who helped write this week’s soda-tax NEJM article.

What’s the point of the misleading opening in the NEJM paper (apart from getting some additional citations for the authors’ other work)?  The line suggests that drinking sugar-added beverages causes heart disease, yet no evidence suggests that.  Extra calories might add up to extra weight, some people (less than half) who have BMIs in the “obese” range report having diabetes, and diabetes can predispose to heart disease — but the NEJM authors make it seem that the sugar-heart connection is somehow direct.  The point is to create an impression of uniform and unavoidable harm. Who would want to be for heart disease?

The supposition that obesity is a terrible illness responsible for broad impairments to Americans’ health — a premise that the soda tax depends on –  is amply and cogently criticized in a series of posts by Sandy Szwarc at Junkfood Science (start here, for instance, or here).  In fact, epidemiologic studies point to a relatively small effect of obesity on mortality, primarily at the upper end of the weight-for-height (body mass index, BMI) scale.  A careful analysis of national survey data from a few years ago (Flegal et al., JAMA 2005) shows that the effect of high BMI on mortality has been declining over time and almost entirely vanishes after age 70.  In fact, some studies point to a protective effect of high BMI for older Americans.

And the claim that increasing the price of sugary beverages is a suitable inducement to Americans to change their behavior rests on standard — but flawed — economists’ analysis.  It’s rational choice theory come home to roost at your refrigerator door.  If you know that it’s going to cost two bucks and a half to replace that 2-liter bottle of root beer in the fridge, you’ll drink it more sparingly than if it cost only $1.29, the theory goes.  Here is where the regressive aspect comes in.  It’s primarily to the poor that coming up with $2.50 for a bottle of root beer seems substantially more difficult than $1.29.  Here, the soda tax reveals itself as just another attempt to get members of what is perhaps America’s most despised ethnicity — the poor — to “fix” their behavior.

And it all rests on a premise so common we might call it the American assumption:  that people only do things that might harm their health because they don’t know any better or because they can’t stop themselves.  Ergo, laws and rules, to make sure everyone knows where and how to draw the line — taxes, bans on smoking in restaurants (or, perhaps soon, parks) and bans on serving trans fats, removal into foster care of kids whose mothers use drugs, prosecution of parents whose kids are too fat, et cetera.  And of course, we need the products that will provide substitute enjoyment or relief.  Thus:  sugar-free soda, trans-fat-free potato chips, Prozac and other SSRIs, diet books, gyms, alcohol-free beer, and so on.

And we need it all to be wrapped up and rationalized in the language of avoiding risk.

Apparently, it isn’t plausible to the doctors and scientists who wrote the NEJM paper, or the legislators who are eager to institute the proposed soda tax, that people might drink too much soda — or eat too much, or smoke, or stay home and watch TV instead of jogging — with full awareness of the possible consequences.   In the risk-free zone of America as envisaged by the public health industry, only the insane and the uninformed would engage in “risky behavior.”

Nobody, in risk-free America, does anything because it feels good, knowing it might be harmful.  Nobody overeats because it brings her pleasure, nobody screws without a condom because it turns him on, nobody smokes because she had a bad day or a good day or because the day hasn’t started but it looks unpromising, nobody rides her bike without a helmet because she likes the feel of the wind in her hair.  It’s risky.  We all know better.

The libertarians think it’s big government you give up your private choices to, and the progressives think it’s big business.  But really, it’s neither — or both, working together.  And the public health and medical industries are complicit.  It’s not a conspiracy.  It’s more like religion.

By Philip Alcabes | September 18th, 2009 | Categories: Behavior, Disease, Health Professions, News, Physicians, Risk, Uncategorized, obesity, public health | Tags: , , , , , , | Comments Off

Medicine and Magic

In his post at The Atlantic yesterday, Abraham Verghese made the case that magical thinking is a powerful driver of debates over health and health care.

“We all want to believe that a pill or potion that comes from sea coral or from the Amazon jungle will cure that pain for which little else has worked,” Verghese writes.  The “flip side,” he says, “is that we are extraordinarily sensitive to any suggestion that someone is taking away something we think is good for our health.”

And magical thinking’s influence isn’t limited to cruising the natural supplements aisle or reading the ads in a health magazine.  Sometimes it’s part of expert opinion — and so it becomes part of widespread belief.

Consider how the flu experts talk about the possibility of swine flu’s return this fall. In Monday’s Washington Post, the experts’ words wax electric.  Dr. William Schaffner, chair of Preventive Medicine at Vanderbilt U.’s medical school, asserts that “The virus is still around and ready to explode…. We’re potentially looking at a very big mess.” And Dr. Arnold Monto, a physician epidemiologist at U. Michigan’s School of Public Health, worries “about our ability to handle a surge of severe cases.”

So, even as H5N1 reports that an article in The Independent finds scientists skeptical as to whether there will be a so-called second wave of serious flu outbreaks in the northern hemisphere this fall, we’ve got American scientists suggesting — in high-voltage terms — that something awful is going to happen.

They’re not wrong: something bad might happen.  That’s always true.

But language matters.  And language coming from so-called experts matters a lot.  It has magic.

Vigorous metaphors promote popular fears.  The last time swine flu came around, in early 1976, respected virologist Edwin Kilbourne published an influential op-ed piece in the NY Times (13 Feb 1976), called “Flu to the Starboard! Man the Harpoons! Fill with Vaccine! Get the Captain! Hurry!” Kilbourne urged officials to prepare for an “imminent natural disaster.” Fair enough:  a serious H1N1 flu might have happened in ‘76 (it didn’t) — but his whaling metaphor appealed to more than just preparation.  It was about power and authority (”get the captain!”).  Presumably, the authority of science, industry, and government.

And so with other metaphors that are meant to be calls to arms.  There were the warfare metaphors about the alleged threat of bioterrorism, and the plague metaphors about AIDS.  Now, there are explosive metaphors about obesity.

Last year, acting U.S. Surgeon General Dr. Steven Galson called childhood obesity a “national catastrophe,” for instance.  And Dr. Risa Lavizzo-Mourey, president of the Robert Wood Johnson Foundation, warned of obesity’s “corrosive” effects, which, she asserted, imperil a generation of America’s youth.  According to Dr. Matthew Gillman of Harvard “You build [obesity] up over generations” — like an electrical charge in a capacitor, like explosive potential, the reader has to presume.

Talking about childhood obesity, Dr. Eric Hoffman of Stanford told the Washington Post that “we have taught our children how to kill themselves.”

Invoking metaphors to create magical thinking isn’t just an American habit.  Childhood obesity is a “time bomb,” according to physician Howard Stoate, chair of Britain’s All-Parliamentary Group on Primary Care and Public Health.

Verghese’s right.  People can be afraid to let go of what they believe they need for their health — however magically.  And magical thinking is inside the way our experts talk to us about health.  That sort of magic can run deep.

By Philip Alcabes | August 13th, 2009 | Categories: Disease, Health Professions, Myths, Narratives, Physicians, Uncategorized, obesity, public health | Tags: , , , , , , , , , , | Comments Off

« Older Entries