The startling results of this study suggest that when left unchecked texting and other widely popular methods of staying connected can have dangerous health effects on teenagers.

(Aside to Dr. Frank:  C’mon, doc.  Do you not know that “hyper text” is already a term in wide usage? Do you know how sometimes there are underlined words, most often in blue, that, if you click on them with your mouse then you are magically transported to another website?  That’s it.  Do you realize that any teens who aren’t already laughing at you for your transparently hysterical research agenda have cause to snicker over your misuse of contemporary language?  But back to my point…)

The subject of a press release by the American Public Health Association, the study claims that teens who text  more than 120 times a day are, compared to light texters:

• 41% more likely to have used illicit drugs
• Nearly 3.5 times more likely to have had sex
• 90% more likely to report having had four or more sexual partners

The results were based on a survey of over 4,000 high school students in the midwest.

The paper, presented at the annual meeting of the APHA, is yet another indicator of the association’s redirection — from promoting social reform to becoming the Popular Front for the Promotion of Family Values.   The news media complied with the APHA’s mongering by publicizing Frank et al.’s findings, for instance here, and so did the usually serious WebMD.

Research like this is meant to say both “childhood is deadly” and “children are dangerous.”  Teenagers have sex, it says, and you grownups shouldn’t take that lightly.

The connection of teen sex and teen drug use to cell phones, iPhones, or the Internet appeals to people who think there is something new, and terrifying, about modernity.  As Carl Phillips notes over at ep-ology, it’s a way of saying “Beware the scary new technology!  It is causing teens to interact.”

Of course, there’s also a race, class, and sex angle:  The study reported that excessive texting (along with what the authors call “hyper-networking,” meaning excessive use of social network sites) is more common among girls, racial minorities, and kids whose parents have less education. One more reason to be suspicious of the poor and the dark-of-skin, says the Popular Front.

Especially, the APHA wants us to beware of girls.  The public health industry — the folks who reminded your grandparents that female sexual desire spreads disease with posters like this one, from the ’40s:

Source: U. of Minnesota, Social Welfare History Archives

… now tell us to watch out for girls who text.

Mike Stobbe at AP, covering the report, did a (typically) good job of looking deeper into the question.  About half of kids between the ages of 8 and 18 text each day, and the ones who do average 118 texts per day. While texting while driving is a really bad idea, texting about sex isn’t uncommon (Stobbe points out).  Unlike texting while driving, nobody dies from it.

Public heath shouldn’t be a matter of, as the Frank report put it, wake-up calls for parents.   Childhood really is dangerous in some places (Somalia, Congo, and Haiti come to mind, in case physician-researchers currently obsessed with sex amongst American teenagers are looking for something useful to do with their medical skills).  But it isn’t in America.   Sex, even between teenagers, really isn’t very scary.   There are a lot of things we adults could do to make the country and the world less miserable, but spying on our kids isn’t among them.

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.

At The Great Beyond, Daniel Cressey notes that Dr. Gerberding, while at CDC, was accused of promoting the Bush Administration’s agendas at the cost of scientific accuracy.  Naturally, now that she is heading for Merck, many are concerned about what looks like a cozy relationship between official agencies and pharmaceutical companies.

Merck says that its vaccine arm is worth $5 billion.  It “markets vaccines for 12 of the 17 diseases for which the U.S. Advisory Committee for Immunization Practices currently recommends vaccines,” according to the company’s press release.

Dr. Gerberding was close to the vaccine world as head of CDC. In fact, during her tenure there CDC’s   Advisory Committee on Immunization Practices (ACIP) called for the implementation of immunization against human papillomavirus and varicella zoster (chicken pox) virus and the agency pushed for expanded immunization against seasonal flu; within 10 months of her (January ’09) departure from CDC, the ACIP had issued recommendations for the use of anthrax vaccine and Cervarix and Gardasil vaccines against HPV.  Gardasil  is a Merck product.

But the problem is more than the “revolving door” metaphor implies.  To have a door there must be a wall — a clear demarcation between inside and out.   As if corporations (pharmaceutical companies among them) were outside of the official system, eager to get the ear of those inside.

Whereas it seems that there isn’t really much of a wall between official health agencies and big business at all.  To be an official today means taking a veritable oath of loyalty to corporate solutions.  The official has to deal in risk.  She has to be ready to sell risk as a kind of debt:  people should want to avoid risk, just as they avoid debt; but if their behaviors put them “at risk,” they can relieve it through “lifestyle” correction.  You can refinance if you know how.

The correction that allegedly relieves risk usually involves the use of better products. Cut out trans fats,  lower your cholesterol, elevate your mood, hop on a treadmill, lose weight, drink responsibly, get seasonal flu vaccine, get swine flu vaccine, wait patiently while the full-body scanners are used at the airport, eat more vegetables, wear sunblock, use hand sanitizer.  Health officials’ job is to get the means for personal risk reduction to the sorry at-risk population.  Have hand-sanitizer dispensers installed in public buildings.  Distribute condoms.  Publish recipes for healthy meals.

Notably, health officials are not supposed to argue for any of the things that would actually make a difference to the public’s overall health:  redress wealth disparities, provide excellent primary care for everyone (including immigrants), or build more decent and affordable housing.  When was the last time you heard a health official call for a campaign against poverty?

The official has to pitch personal risk reduction, in other words.  She has to be ready to support high-cost, individualized approaches to improving the public’s health — or well-being, which, Dr. Michael Fitzpatrick astutely notes at Spiked!, has replaced health as the main objective of modern Good Works .

Health officials keep faith with the dogma of risk avoidance.  Corporations preach risk reduction and peddle the wares by which people can restructure their lives — and avoid risk.  The wall separating government policy makers from corporate solutions gets more and more flimsy.

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?

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.

Joshua Holland’s post at AlterNet yesterday tries to explain why H1N1 swine flu shouldn’t be cause for hysteria.  He puts this outbreak in the context of flu history and the threat posed by other, more harmful, conditions — malaria for instance.  Holland plays a little bit fast and loose with the numbers:  it probably isn’t accurate to extrapolate, from the number of confirmed flu deaths so far, to get a total number of deaths that will be caused by the swine H1N1 strain this year — more efficient spread in the  cities of the Northern hemisphere in the coming few months is likely to produce fatalities at a higher rate than the more sporadic outbreaks here in April and May.  And he’s overly critical of the media — a point brought out by Revere in a response to Holland at Effect Measure today.

But, as Frank Furedi has been telling us (recently in Erasmus Law Review, for example), try to explain how people’s deep-seated anxieties drive perceptions that risk is extraordinary and unprecedented (and contribute to demands for more and better high-cost technology to deal with it) and you get some people riled up.  Disappointingly, even Effect Measure, whose assessments are consistently level-headed and cogent, slips here, flashing the moral-entrepreneur card at Mr. Holland:

Joshua Holland has never cared for a critically ill person with Acute Respiratory Distress Syndrome (ARDS), which is often the terminal event for flu patients. So I’ll tell him. It doesn’t matter if it’s caused by bacteria (many are). Half of them die no matter what you do and no matter what intensive care unit you have available to you or what antibiotic or what computer controlled respirator. We still can’t do much.

Nobody thinks it’s a good idea to let people get ARDS, and Holland acknowledges that flu is a problem that should be dealt with.  But that’s not always enough.  Question the intensity of perceived risk or the need for all the technology, and you find this out fast.

But Revere is back on track when noting that lots of problems — including malaria — are horrendous and deserve attention, and probably don’t get it because they happen to people far away.

Where would the impetus to deal with global problems besides flu come from?  A global organization that can keep things in perspective would be useful.  Poor W.H.O. isn’t positioned to do that.  Yesterday’s flu advisory from W.H.O. emphasizes the use of antivirals (oseltamivir and zanamivir) to treat people with severe or possibly severe flu:

Early treatment is especially important for patients who are at increased risk of developing complications, those who present with severe illness or those with worsening signs and symptoms.

Yet, the W.H.O. also warns against hastening the development of resistance.  This agency gets a lot of flak for not doing more and for panic-mongering when it does do more.  But, really, it’s only doing its job:  offer advice, and support interventions when invited.  It isn’t consistent, naturally.  It can’t make binding policy.  It faces a limitless and essentially insuperable legitimation problem.  In a way, W.H.O.’s hardest job is simply to maintain its own legitimacy.

Still, in a world poised to interpret signs of illness as evidence of risk and eager for technical fixes to alleviate the sense of vulnerability risk instills, the W.H.O.’s announcements can seem authoritative — and look like beckoning to the drug makers.  A Reuters story yesterday is entitled “Early Use of Antivirals Key in H1N1 Flu: WHO,” and highlights the value of the two antiviral medications more than the caution W.H.O. wants to instill.

Meanwhile, agencies that should be making real policy are focusing on immunization.  In today’s Washington Post, Rob Stein reports on health care workers’ resistance to mandatory flu vaccination.  New York State made flu immunization mandatory early on, not only for salaried health care workers but for anyone — including medical and nursing students — who might come in contact with patients, and is putting teeth into the requirement with sanctions for refuseniks.  The state resorts to high  moral rhetoric to justify its policy.  The state’s health commissioner told Stein that “the rationale begins with the health-care ethic, which is: The patient’s well-being comes ahead of the personal preferences of health-care workers.”

And at CDC, the director is cautioning that there might be a rough start-up to the swine flu immunization campaign, as the first doses of vaccine will be made available in early October.  According to the NY Times, there should be 40 million doses of vaccine available by mid-October.

We wonder whether immunization will be of any public health value at all, by the time there’s enough vaccine that it can be offered to anyone other than health care workers and a few of the people who really need protection (young people, infants’ caregivers, and pregnant women, especially — DemFromCT’s round-up at DailyKos is always worth reading).  Given the rapidity of spread of flu — in 37 U.S. states, H1N1 spread is already regional or widespread; flu is spreading locally in 12 more states, Puerto Rico, and Washington, D.C. — and based on the usual course of flu outbreaks, it seems possible that this outbreak will peak by mid November.  There’s no knowing if that will be so, obviously.  Even if it is, immunization would continue to be useful to prevent severe cases among people who are likely to get very sick if infected.

But mass immunization would no longer be of much use in preventing further incidence of infection on a population level if high levels of acquired immunity are reached across much of the population by the time vaccine is widely available.

That’s the problem with relying on mass immunization as the centerpiece of public health response: as in the old joke about comedy, timing is everything.  In 1976, there was too much immunization, too soon.  It might turn out that this year, there’s too little, too late.  The dynamics of vaccine availability and the dynamics of flu spread have to be watched in tandem, and policy updated accordingly.

In any case, with vaccine at the center, the rest of the story — the complex environmental interactions that allow flu genomes to recombine, the trade in animals and feed that allow viruses to move around, the problems of affordability and immune status and competing viral subtypes, the health care facilities to handle severe cases, and so on — gets shoved to the side.

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.

“Deadly Choices” is heartbreaking.  It recounts a situation that was miserable, terrifying, and in some cases, fatal.  Fink reports that, among 45 Memorial Medical Center patients who died in the days during and immediately following the storm, 17 were deliberately administered lethal doses of morphine, sometimes along with a sedative, by physicians who apparently intended to hasten the patients’ deaths.  (Many of these 17 were patients at a hospital-within-the-hospital, a long-term care hospital under separate ownership that shared some staff with MMC.  At Slate today, Josh Levin discusses some of the troubling truths about the financing of long-term care hospitals, and Fink fills in some more of the blanks with a response at ProPublica.)

As Fink explained to Amy Goodman in an interview with Democracy Now earlier this week, at least one of the patients who were killed was not in extremis; he had not given up.  He was

“Ready to rock and roll, wanted to get out. And apparently, according to several people who later spoke with investigators, a discussion was had in which they talked about how they might get him out, and they decided that because he was so heavy and it was so hot and people had—I mean, just imagine….They had been going on no sleep for days, the medical workers. They were tired. They were terribly disturbed by all the suffering that they felt that they saw around them. And so, in this sort of moment, they apparently decided that [the patient] could not be brought down, could not be evacuated, that there was no way to get him out.”

The story of what happened at MMC is also profoundly disturbing.  It moves us to ask what sort of moral world physicians are expected, and allowed, to operate in.  And to wonder why moral boundaries should be so elusive to exactly the people who, with access to the means to both prolong life and hasten death, walk on morally fraught territory more often than anyone.

The horrifying events at MMC are especially  germane today — because they highlight a vexing question about health care reform that is very hard to answer:   Is our doctors’ job to alleviate suffering, or is it to improve health?

A favored guru on health care ethics, Ezekiel Emanuel, is explicitly in favor of the latter.  In “Justice and Managed Care” (subscription) in Hastings Center Report in 2000, he writes

“The allocation of health care resources should aim at and be justified by the improvement in people’s health…. The special aim or purpose of health care is curing disease, relieving pain and suffering, promoting public health, pursuing research to improve health, and so on.”

The “and so on” means that improving health — the obligation of a health care system, Emanuel asserts — amounts not just to the relief of pain and suffering but also to research and public health, and other tasks as well.  The relief of suffering might not be a priority, that is.  Or it might be a contingent priority, of importance for a limited time, or in certain circumstances — but not the only thing to worry about.

The point is not to vilify Emanuel.  He has opposed euthanasia and physician-assisted suicide, so we should assume that he was as appalled by the actions of the chief physicians at MMC as others were.

But the Emanuelian sensibility is that the system in which physicians work is not meant to be dedicated to the relief of suffering alone.  Rather, it bears other duties as well:  a broad obligation to the public to promote health, and another obligation to contribute (through research) to the future of health care.

In this narrative, the physician is marshal of a campaign — not merely joined in a series of caring relationships with each of a number of patients, but commander of troops who have a long-term goal and territory to win.   By implication, the rights of patients might take second seat to the needs of the public, or to the desire to learn more about how to improve health in the future.  Patients shouldn’t be killed, this thinking goes, but they will have to understand that the prolongation of life is a luxury commodity to which physicians have the keys — and not everyone can have access.

The sense of the physician as a responsible manager, not merely a giver of care, connects with the utilitarian credo, “the greatest good for the greatest number” — a phrase that occurs three times in Fink’s piece as she strives to characterize the sensibility of MMC providers.

But the killings at MMC should, at the very least, make us ask whether it’s a good idea to have doctors making decisions about the greater good — or whether we want them to recognize individual persons above all.

This week, the city’s health department announces that it wants to require thousands of retailers who sell tobacco products to put up posters with the same disgust-inducing images – as Jennifer 8. Lee noted at the Times‘s City Room blog on Wednesday and an AP story (picked up by Newsday) explained on Thursday.

And it won’t be little stickers the stores are required to put up:  these posters would have to be at least a foot-and-a-half square.

It looks like the city’s health agency is going to continue its program of treating New Yorkers like we’re stupid and reckless, despite the departure of the bluenose Dr. Thomas Frieden (who left NYC to become CDC Director this month).  The prevailing view at the health department seems to be that officials have to keep sermonizing or we dumb slobs will slide back into bad habits.

As Jan Barrett noted Thursday, people who smoke nowadays know quite well what they’re doing, and why.

Barrett, an ex-smoker, notes that “every time I lit up a cigarette I was fully aware of what it was doing to my body. I mean how can any smoker not know these days what smoking can do to them? There are warning signs everywhere. I don’t care how many warning signs I saw or heard about I still lit that cigarette every morning.”

The health department claims that negative advertising will help convince smokers they should quit. But smokers don’t need to be convinced — about 70% of smokers have tried to quit, and (as the above comment exemplifies) some of those who don’t quit are aware of the dangers but smoke anyway.

The department also claims the gruesome-ad campaign will dissuade teens from taking up smoking to begin with.  But retail stores wouldn’t be the place to post the ads, then – since the shops aren’t permitted to sell to minors in any case (nor would TV: if it were teenagers who were watching baseball games, there wouldn’t be so many Viagra ads).

We might think that resorting to a signage campaign like this is a cover-up for inactivity, but it isn’t:  the health department already runs a vigorous program of smoking-cessation activities , which can include nicotine-replacement therapies.

No, the new gruesome-poster initiative isn’t about health; it’s closer to religion.  The images of smoking-induced damage are iconography.

Frank Furedi calls this sort of thing secular moral entrepreneurship.

The iconography of the religion of risk avoidance is meant to remind sinners – people who eat the wrong foods, don’t exercise enough, have sex without condoms, fail to take medication for our depression, or smoke cigarettes — that it might be rigorous to follow the True Faith of Health, but it’s worth it.  “Look at how others have suffered in order to learn what you now know,” they say.  “How can you go on with your nasty ways when you’ve got a chance to save yourself?”

The city’s new health commissioner, Dr. Thomas Farley, is apparently as ardent as Frieden about browbeating and hectoring people who fail to comply with health guidelines.  The television advertising and the signage isn’t meant to make the population healthier – its job is to remind us how to behave, and the consequences of impropriety.