Philip Alcabes discusses myths of health, disease and risk.

Putting Obesity in Perspective

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

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

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

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

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

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

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

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

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

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

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

AIDS Goes to Ground

This week, Donald McNeil, Jr. continues his praiseworthy efforts to highlight the sad reality of AIDS among the world’s poor.

In an article posted on the NY Times website Sunday (and published in the print edition Monday), McNeil reports on the inability of treatment programs in parts of Africa (this piece focuses on Uganda) to keep up with the need for AIDS medication as funding falls.   A very compelling video report accompanies the online version of the article.

An accompanying article explains the decline in funding, starting with the fall in the U.S. administration’s request on behalf of PEPFAR, as a Times graphic shows.

The number of new infections with the AIDS virus is estimated to be about 2 million per year now.  Some observers think annual incidence will rise as the population expands; even if not, the annual number of new AIDS virus infections is unlikely to fall in the near future, given present circumstances.

At the same time, the Times reports, anticipated PEPFAR funding is essentially flat to 2013, at $5 to $5.5 billion per year.  Financing for AIDS medications through the Global Fund to Fight AIDS, Tuberculosis and Malaria is in dire straits.

In terms of people, not dollars:  of the 33 million or so individuals who are infected with the AIDS virus worldwide, only about 4 million get regular antiretroviral therapy.

A few years ago, I wondered why,  after a quarter-century of AIDS and with the availability of effective treatment (at least in wealthy countries), Americans still didn’t see AIDS as an ordinary illness.

Now I have an answer:  we do see AIDS as ordinary… for poor countries.  To us, AIDS is no longer an epidemic problem worth our getting worked up over, or so it would seem judging by PEPFAR.  AIDS is like malaria, tuberculosis, or schistosomiasis.  It’s like diarrhea.  The Bill and Melinda Gates Foundation will put money into research or specific programs but we as a country will not need to care anymore.  We shift the funding away from the people in Africa, who are going to die young anyway, and put it into the hands of institutions (often, pharmaceutical companies) that can give us the promise of immunity from disaster.

The U.S. put less funding last year into PEPFAR than it did into preparations for H1N1 flu ($7.6 billion) or the school lunch program ($14.9 billion, according to the Robert Wood Johnson Foundation’s Center to Prevent Childhood Obesity), battleground in the war against childhood obesity.

Flu and obesity are epidemic.  They threaten American assumptions about ourselves.  “Epidemic” means:  crisis in our society.  Our epidemiologists say that malaria, diarrhea, and the other problems that collectively kill 20,000 or 25,000 people (mostly children) every day are endemic

“Endemic” means:  not our problem.

AIDS is endemic too, now.  It has gone to ground, gone the route of other once-dreaded infections that caused calamity in America and triggered heated debate (yellow fever, cholera, typhoid, TB) but have disappeared from our scene.  It’s their problem, now.

New Year’s Wishes for Public Health

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

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

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

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

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

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

The Anti-Obesity Crusade Invades Academia

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

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

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

But pay attention to the commentary.

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

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

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

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

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

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

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

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

Obesity and Public Health Control

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

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

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

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

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

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

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

From Junkfood Science, we learn that

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

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

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

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