The subject is a report published by CDC today claiming that obesity among NYC schoolkids in grades K through 8 has decreased 5.5%.

The city’s health commissioner, Thomas A. Farley has been true to the shades of history’s empty-headed warriors.  Farley announced that the drop in obesity prevalence is a “turning-point in the obesity epidemic” although it “does not by any means mark the end.”

A missed photo opp:  Dr. Farley standing on top of a fat child, holding up a sign reading, “Mission Accomplished.”

Farley is zealous about controlling people’s behavior and contemptuous of facts (nobody will ever accuse him of being an intellectual, either).  He blogs about his own work for the exclusive reading pleasure of Department of Health staffers.  This allows his staff to read the Farley-esque twist on truth.  One example for now:  in October of 2010, Farley’s blog exultantly told his staff that in 2009 the department had “immunized nearly 130,000 children [against flu] in more than 1,200 schools over a few months.”  Of course, health department employees are smart — many of them knew that the 2009 H1N1 vaccine Farley was talking about was a fiasco, far too late to make a difference, and aimed at an outbreak that was more of a whimper than a bang.

What about today’s “turning point” in the obesity war?  It’s worth noting that the supposed drop in obesity among NYC schoolkids is really just a very slight (1.2%) difference in the prevalence of obesity between 2006-7 and 2010-11.

A small difference between small numbers amounts to a large percentage difference.  So the 1.2%  actual difference magically turns into the advertised 5.5% — the proportionate change.

But the false advertising gets worse

1.  The prevalence of obesity in NYC was not measured multiple times on the same group of kids (to use epidemiology jargon:  this wasn’t a panel study).  Nobody observed fat children becoming less fat.  The city simply measured obesity prevalence each year on 5- to 14-year-olds who were in the school system.  So a high proportion of the 21.9% of kids who were labeled obese in 2006-7 would have been out of the age range for the 2010-11 assessment.

Plus, lots of kids leave the NYC school system after grade school (this has to do with Bloomberg administration’s bizarre system for preventing children from attending local schools).  So, even those children who haven’t aged out of the analysis by turning 15 would be absent from the data after a few years.  And, there’s also natural immigration and emigration.

Did the 2006 fat kids get slimmer?  Nobody knows.  The 2006-7 obesity prevalence among NYC schoolkids (21.9%) can’t be compared to the 2010-11 prevalence (20.7%).  If you were forced to compare these numbers, you’d say there had been a slight change — not a 5.5% decline.  There’s the first lie.

2.  The second lie is a little more complicated.   Since there is no widely accepted functional definition for childhood obesity, children are labeled obese if their body-mass index (BMI) falls into the upper 5% of the expected distribution of weight-for-height.  This expectation is based on an old-fashioned standard.  Fair enough.  But lots of distributions shift over time — SAT scores, human height, grades awarded at Ivy League colleges, and global average temperature, to name a few.

Sometimes the reason for an overall shift of this sort isn’t hard to specify (test prep, nutritional quality, relaxation of grading standards, generalized global warming, etc.).  But the main effect causing a shift in the distribution doesn’t explain why the few people who are in the upper reaches of the distribution are so far from the mean.  To say that fewer children are now above the high-BMI cutoff than in 2006-7 therefore the tendency of children to be fat is declining is a lot like claiming that because 2011 was cooler than 2009 and 2010, global temperatures are not really going up.

(Dr. Farley, I gather that statistics aren’t your strong suit, but surely when you witnessed that snowstorm we had this past October — an outlier if there ever was one — you didn’t conclude that the climate is actually getting colder, not hotter.  So what makes you think that a very tiny decrease in the proportion of kids with high BMIs means that the city’s kids are getting slimmer?)

3.  Claiming credit.   Attributing to the health agency’s own efforts a minuscule change in the proportion of kids who are in the upper tail of the broad BMI distribution requires self-congratulation so acrobatic as to stretch credulity.

Maybe there really has been some change in the city’s children since 2006.  Or in our food supply or buying habits.  Or exercising.  But to claim that such a change both caused the tiny decline in schoolkid obesity prevalence and that it was the result of the Health Department’s efforts — the exercising and the low-fat milk and the salad bars in the school cafeterias and so forth — is to commit the fallacy that Rene Dubos outlined (in his book Mirage of Health) nearly 50 years ago:

When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail.

Is childhood obesity really a health problem?

It’s not crazy for health professionals to be concerned about body mass.  Obesity might be really bad for some people, and somewhat bad for many.

But those people are adults.  Why are health agencies like NYC’s so riled up about obesity in little children?

So far, there’s no strong evidence that obesity in younger children predicts any real harm later in life, other than being a fat adult.  With adults, several signs of impending debility are more commonly found in the obese than the non-obese, such as hardening of the arteries, fatty liver, sleep apnea, and diabetes.   And with adolescents, there’s some evidence that those who are obese develop similar warning signs.  But not younger kids.

A 2005 BMJ paper reported only social effects in adulthood (being unemployed and being without a romantic partner) of early obesity.  Similarly, one cohort study carried out in Newcastle upon Tyne found little evidence that fat children became fat adults, and no evidence for predictors of illness in adulthood among those who had been overweight as children — although other studies have shown correlations between adolescent obesity and adult problems.

For kids below age 15, the most visible problem with obesity is that it occurs most commonly among the poor and dark-skinned.  This bothers the obesity warriors.  In fact, not only is obesity more common in African- and Hispanic-American children in NYC, even the slipshod standards of today’s report on NYC schoolkids can’t be manipulated to show that obesity is declining among these children.

As with all holy wars, from the Children’s Crusade through the U.S. invasion of Iraq, the warriors aren’t really concerned about principle.  Something about somebody got under their skin.

Here’s how I answer my own question:  I guess the obesity crusaders don’t like it when the children of the wealthy look like the children of the poor.  They think that white kids on the Upper East Side aren’t supposed to look like kids who live in the Bronx.

It isn’t about health, in other words.  It isn’t even about obesity.  The “childhood obesity epidemic” is about making sure society looks the way that the health crusaders want it to look.

A paper by David Leon in this month’s International Journal of Epidemiology showed the dramatic increase in life expectancy — the median age at death, that is.  It has reached over 85 years for women in Japan, but it’s high even in countries where longevity was relatively low a generation ago.  Cheeringly, US life expectancy at birth is now 78 years; in the UK it’s 80.  And it’s even higher in some countries of western continental Europe.  Here are the graphs for different parts of the world from Leon’s paper, showing trends since 1970:

Life expectancy since 1970

Lyons has gone after the anti-obesity crusaders before (as well as related topics at his smart blog on contemporary food confusion, Panic On A Plate).  Now, he’s particularly disturbed by the sermonizing about eating. “You can’t even have a pie and a pint without someone telling you it will kill you, it seems,” Lyons writes at Spiked.

And, really, it’s even worse than that — because it’s not just eating that’s the subject of the lecturing.  It might be true that you will live longer if you give up smoking, cut your salt intake, drop your BMI down to 24.99, exercise four times per week for at least 20 minutes each time, get immunized against flu and human papillomavirus, drink in moderation, and take naps.  But unfortunately there’s not a bit of evidence that any of that — apart from the decline in smoking — has contributed to increasing longevity.

And of course, even with smoking cessation, there’s no telling whether it would make any difference to you — only on average.

So why are the public health messages so far away from what really matters — basically, prenatal care, postnatal care, and wealth (with its concomitant, standard of living)?  Well, there’s a puzzle.

What’s the point of having an industry whose main aim is to make sure that people are constantly in fear that they are doing something that will kill them — even as it becomes apparent that most of what people do is only making us live longer?   Lyons calls it Good News Omission Mentality Syndrome (GNOMES).

I ask you:  could it have something to do with control?  And the desire to sell products?

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.

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.

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.

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.

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.

This is a good discomfort, no?  Nobody should blithely take advantage of another person, coercing him into donating his organs or making use of her for sexual pleasure without consent.  Watching Stephen Frears’s 2002 film Dirty Pretty Things leaves you appalled and angry at the kidneys-for-passports trade, as it must.  Slavery is an outrage and an offense, a rejection of the values that make ours a civilized society.   Every thinking person decries the trafficking of women for sex.   In modern society, it feels wrong when one person’s body is used to  advantage another’s body.

The exchange of money in the process seems to change the moral valences without exactly alleviating the discomfort.  That children’s families are paid for their manual labor in processing cocoa for the chocolate we eat doesn’t make the practice of child forced labor seem less heinous.  Maybe we even boycott chocolate manufacturers who use chocolate from Ivory Coast, where child labor is involved.  Taking advantage of children’s bodies disturbs us (even to the point of limiting our chocolate purchases).

Money registers differently when it comes to adult sexual exchange.  In the usual American view, there is a bright line between sexual enjoyment obtained through the use or threat of force, and the same enjoyment procured by payment but without force.   Both forcible rape and prostitution are illegal, but most people would recognize a distinct difference between the moral repugnance elicited by rape and the tinge of moral corruption carried by sexual advantage obtained by payment.

Payment introduces a legal twist to sex, too:  the law holds the man who procured sexual advantage through force to be culpable in the act of rape.  Yet, when it comes to paid sex, the legal code holds the woman who provided the sexual service accountable.  The bluenose might scorn both the sex worker and her client equally, but the law makes a distinction.

By contrast, payment makes all the difference when it comes to the use of someone else’s body for productive manual labor.  Your neighbors would be repelled if you were to use force to make a passer-by reshingle the roof of your house, and might have you arrested.  But they aren’t bothered when you hire a roofer.  Most aren’t very bothered when the roofer has some immigrant laborers do the scut work for below-minimum wage — which seems someplace in between a true fee-for-service contract (you in need of a new roof, a roofer able to build one) and slavery.  When money changes hands, it softens the moral impact of making use of someone else’s body.

But the moral flavor doesn’t disappear.  If your roofer refused to let his immigrant workers come down off the roof during a lightning storm, his meager payments to his workers would feel less important than his endangering their welfare.   In other words, onlookers would still be moved by the moral flavor involved in making use of someone else’s body.

Now for the tricky part. What about the use of others’ bodies for medical research? An article in today’s Times laments the shortage of willing bodies for testing cancer treatments.  Contemporary medical ethics presupposes a human trait called “autonomy” and requires that researchers respect this characteristic – for instance by refusing to experiment on a person unless she has signed a consent form acknowledging that she agrees to be experimented on and asserting that she understands the risks and rewards involved.

Of course, the reward system is often obscure, no matter how verbose the researchers are in the process of obtaining consent – in part because it’s often hard to predict who will benefit if new treatments are deemed to be effective, in part because it’s often hard to know how effective a treatment is likely to be, and in part because a big chunk of the benefit accrues to the researchers (articles published, grants funded, awards won) and the research industry (grant funding justified, administrative costs rationalized).

Nobody would accept a system in which people are forced to become medical research subjects.  In fact, the discoveries at Nuremberg about forced participation in medical experiments during the Second World War gave the impetus to the modern field of medical ethics.

But how much does it change the moral outlook if you are rewarded for allowing your body to be used by medical researchers with a cash payment?  The researcher has to be able to claim that her  subjects are not forced to participate – and the medical ethicists who are attached to the autonomy concept will still worry that the subject’s decision to lend his body for research will be coerced, not free and autonomous, if the payment is too grand.

For some classes of people, including children and addicts, payment is deemed to be especially coercive.  The thinking being that if the researcher were to offer $100  to an addict, the addict would use it to buy dope, and that would be harmful, and therefore the researcher would be doing a bad thing even though her research was really meant to do good.   Physician researchers always need to feel that they’re doing a favor to society (not to themselves).

Meanwhile, others decry payments that are too small, arguing that time, angst, and (sometimes) physical or mental suffering involved in being a research subject ought to be reimbursed at respectable rates.   Although the idea of a professional workforce of permanent research subjects, who might receive a retainer in return for surrendering their bodies and tissues for research, rubs physician researchers the wrong way.

Our society really likes medical research. We don’t want our doctors to stop looking for ways to help us to live longer and more comfortably.   Bodies must be used, but they shouldn’t be used without consent, they shouldn’t be purchased outright (that would be slavery), they can’t be paid too much, they shouldn’t be paid nothing, they shouldn’t be recruited for research use in perpetuity or receive the sort of ancillary benefits of employment that professionals get, and they should preferably not be “vulnerable” (young, developmentally disabled, imprisoned, or pregnant).

Which brings us back to kidney donation.  Should kidneys only be allocated anonymously and through a universal system that provides kidneys in accord with a complex algorithm that takes account of the likely benefit of the transplant?  Should there be a federally controlled market in kidneys, or at least some system that encourages donors through market-value incentives (like tax breaks), as Sally Satel has advocated?  Should there be a fully open market through which you could purchase the organ you need from a suitable and willing donor?

The conjunction of bodies-in-service-to-other-bodies and dollars makes the kidney question — like sex work, child labor, and medical research — fraught with moral meanings.  Simple solutions won’t serve.

Yesterday, according to an Associate Press report, Frieden sermonized that “obesity and … diabetes are the only major health problems that are getting worse in this country, and they’re getting worse rapidly.”  Now, Dr. Frieden heads the agency that collects data on illness and calculates disease rates; presumably, he knows that many conditions are either increasing now or have risen to high levels from which they have not retreated — MRSA, Lyme disease, injuries in certain occupations, and foodborne illness, to name just a few.

But as Dr. Frieden’s campaigns in New York City against trans fats, unprotected sex, and TB sufferers who didn’t take their meds  revealed, when there is a moral battle to be fought the facts just get in the way.

The impetus for yesterday’s obesity sermon was a study by investigators at RTI who had determined that “obesity-related diseases” account for over 9 percent of U.S. healthcare costs.  Most people who suffer from most of the so-called obesity related conditions are not actually obese.  Even diabetes, the one most commonly associated with obesity in the popular mind (and, apparently, Dr. Frieden’s) occurs more often among people who are not and have never been obese than it does among those who are obese.  So the study was really showing that obesity accounts for much less than 9 percent of healthcare costs.

But that wasn’t the only problem.  While the RTI study found that obese people spend 40 percent more than comparison “normal” people on health, most of the increase in spending was related to pharmaceuticals.  So one might ask if it was obesity that was increasing expenditures, or the price of certain drugs.

Furthermore, there’s no way to know whether being fat was causing the obesity group in this study to be sick in ways that cost more money, or if they were fat because they were unwell in the first place.

In fact, the study wasn’t designed to test whether becoming obese led to an increase in medical expenditure — which might have shed some light on the question of whether obesity causes higher costs.  Many people in the study had no  expenditures at all for certain types of healthcare costs.  But the researchers weren’t interested in finding out whether obesity sometimes costs nothing at all, so they used an adjustment technique to allow them to relate obesity to predicted expenditures.

Finally, the estimate of percentage of total healthcare costs attributed to obesity-related expenditure was based on the assumption that obese people who return to “normal” weight suffer no consequences of their weight loss — an assumption that is well known to be false.

So it’s a falsehood to state on the basis of the RTI findings that obesity is accounting for a tenth of American healthcare costs — although AP, Reuters, and other media outlets so claimed in covering the Frieden sermon.

In fact, a lucid assessment of the findings would ask why, if obesity is supposedly up 37% among Americans and if two-thirds of Americans are now overweight or obese, obesity would account for only 9% of costs?  Surely if obesity is so bad, increasing its prevalence by more than a third would be swamping the healthcare industry with fat people.

But the whole appeal of a sermon is that it isn’t based on fact or lucid assessment of the present reality. It’s based on suppositions about the future with a steadfast moral foundation.  Frieden has the supposition and he has the moralism.  His religion is that it’s up to the “community” to perfect itself.

As Shirley Wang at WSJ Health Blog reports,  Dr. Frieden believes that  increasing availability and decreasing price of healthy foods, while decreasing availability and increasing  price of unhealthy ones, “is likely to be effective.” He claims that the decision to adopt such a strategy “is a political one.”

But of course it isn’t political in its essence; it’s moral.  When the community is told to perfect itself it rises to the occasion by looking to the usual moral suspects:  women, especially pregnant women or mothers; the uneducated; the poor.  Last fall, Frank Furedi discussed the moral underpinnings of British authorities’ removal of fat children from their parents’ homes.  And we can hope he’ll have something to say about what’s happening in the U.S., where the community policing can be even worse:  a few days ago, a South Carolina mother was arrested and charged with neglect for having a son who weighs over 500 pounds.  Other states have contemplated other methods of dealing with parents who violate the community standards of parenting.  Not by hitting their kids, starving them, or forcing them to work — but by allowing them to get fat.

Obesity is offensive, it seems, in just the way that sexual license and intemperance with alcohol have been found offensive by some.  And just as the problem with sex and drinking has been found in the environment — in “peer pressure,” the “latchkey phenomenon,” TV advertising, Hollywood, and the decline in “family values” — so it is with obesity.  “We did not get to this situation … because of any change in our genetics or any change in our food preferences,” Frieden adumbrated.  “We got to this stage of the epidemic because of a change in our environment and only a change in our environment again will allow us to get back to a healthier place,”

It isn’t obvious what to do when appetites produce offense — so it’s handy to claim that the environment is at fault and then to hand the problem to public health.  Because for certain health officials, it’s always clear what to do:  Take the moral high path, clean up the offending elements, urge the community to police itself better.  If more parents are arrested… well, perfection has its price.

Back in April, a fast-food establishment in Leytonstone, in the northeastern part of London, was shut down as a public-health threat.  As Patrick Hayes explains at Spiked, a 2009 initiative of the local council, called the Sustainable Community Strategy, outlaws the establishment of new carry-outs within 400 meters of a school.

Supporting the rhetoric, Professor Kathy Pritchard-Jones, president of the European Society for Paediatric Oncology, stated in February that “If we don’t … tackl[e] how much exercise our young people take and how concerned they are about what they eat and their weight, we are going to have another explosion of cancers.”

Last week, the U.K.’s Environment Secretary, Hillary Benn, invoked the fight against obesity as rationale for increasing access to open spaces, asserting that “green spaces are good for us” – a pitch which moved Spike’s sharp-eyed Rob Lyons to note that “You can’t even go for a stroll these days without it being turned into a health initiative,” and to anticipate that “chubby people [will be] quick-marched around a south London park for 30 minutes on a regular basis to help them lose excess pounds.”

There are so many pieces to the fanfare over the “obesity threat” that it’s impossible to assign one cause for the commotion. For a long time, Junkfood Science has investigated the sociology of the “science” of obesity in detail, and has exploded many of the central myths of the anti-obesity movement – most importantly the apocrypha about fatness and mortality.

And Paul Campos’s brilliant book The Obesity Myth (Gotham, 2004) explains how a constellation of wealthy industries together support the lose-weight-now rhetoric.

Elizabeth Kolbert’s assessment of some new books on the topic in this week’s New Yorker embraces the tired rhetoric, assuming that fat is bad and asking why people eat so much.  To her credit, Kolbert takes the plunge into examining the new field of fat studies.  But she ends up disparaging fat studies for “effectively all[ying] itself with McDonald’s and the rest of the processed-food industry, while opposing the sorts of groups that advocate better school-lunch programs and more public parks.” Apparently, asking that fatness be examined in the context of both social structures and individual liberties strays too far from the central dogma of the anti-obesity crusade.  To which (pace Hillary Benn) public parks are balm and tasty fries are anathema.

But an often-neglected aspect of the anti-obesity panic is the overtone of class and the undertone of race. In Leytonstone, for instance, it turns out that the community has been troubled by the profusion of cheap eating establishments, especially in regard to the “anti-social behaviour” that it supposedly brings.

Yet, as Hayes notes at Spiked, it was a Jamaican establishment that was singled out for closure – while more echt-English outlets, like fish-and-chips shops, have been ignored.  The decision that behavior is anti-social being always in the eyes of the beholder – or the skin color of the beheld.

In most of the developed world, fatness is more common among the poor.  In the U.S., it is far more common among African Americans.  Obesity is a marker for being out of power.  To assert that you are against obesity is to state that you intend to identify with those who have power, and mean to keep it.  You can wag your finger at the misdemeanants who eat fast food and fail to exercise — without having to come out and say that what is really troubling you is that your people are starting to look like those people – like the poor, like the dark-complected … like the fat.

No wonder the anti-obesity rhetoric has heated up in Britain, and is catching on in Europe.  It’s a winning way to wage the war against the poor and unentitled, without having to seem arrogant or racist.

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.

Frieden tried hard to reconfigure the role of the health official in 21st-century America.  He seemed to have recognized that health is on the main stage now in the policy theater.  And he’s been searching for a new role for the public-health physician.  As DemFromCT points out in yesterday’s DailyKos, Frieden handled the swine flu crisis well.  All good.

Still, it’s hard to applaud Frieden for his work during his tenure as commissioner here in NY.  Perhaps he couldn’t stand in the way of the moral juggernaut driven by mayor Mike Bloomberg.  Or maybe Frieden’s medical focus makes him share some of Bloomberg’s fervid disdain for the nasty bits of urban life — the smoking, the quick noshes, the hook-ups — even if not the bluenose moralism.  What can’t be denied is that Dr. Frieden and Mayor Bloomberg together promoted the myth that bad health is purely a matter of bad behavior.

The myth was an alarming break with the reality of the real causes of poor health, but it played well.  There was the ban on smoking in bars, the ban on serving trans fats, the constant hectoring about what we eat and how much of it, and the finger wagging about AIDS “complacency” and our failure to use condoms.  There were the restaurant closings on account of violating the health code (that was after the City’s health department had been embarrassed by media reports of rats in a number of food establishments).  Those were aspects of the stagecraft that has characterized the Bloomberg reign in NYC, but none of them had much impact on the city’s health.

What there wasn’t, under Bloomberg-Frieden, was any discussion of how to improve health through providing better housing – and Dr. Frieden seems to have raised no objection to the mayor’s new plan to charge homeless people rent for staying in city shelters. In fact, housing was off the health agenda entirely – although it has always been on Bloomberg’s, usually in the form of deals that would sell to developers middle-income housing or the land it stands on — even though decent housing would arguably have made more difference to the health of more people than trans fats ever would.

Neither did Dr. Frieden ever publicly argue for funding for public schools or prep-for-college programs on the grounds that education translates into better health.   Great opportunities for real change were passed up in favor of preserving the myth of behavioral risk.

In the recent crisis over swine flu, Frieden was statesmanlike – and we have to hope he’ll show similar circumspection and gravitas as CDC Director.   At Effect Measure, revere points out the need for good management at CDC.  But we also have to hope that, once free of Bloomberg, Dr. Frieden doesn’t bring the same moralistic sermonizing to the matter of disease control.