Philip Alcabes discusses myths of health, disease and risk.

America, Free of Risk: Taxing Soda

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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This entry was posted on Friday, September 18th, 2009 at 7:55 am and is filed under Behavior, Disease, Health Professions, News, obesity, Physicians, public health, Risk, Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. Both comments and pings are currently closed.