Philip Alcabes discusses myths of health, disease and risk.

Iconography of Risk

For some time now, watching a ballgame on TV has meant sitting through sappy commercials that advertise remedies for what we’re supposed to call “erectile dysfunction.”  This season, at least in New York, the baseball viewer who isn’t quick with the remote will be treated to gruesome negative advertising about smoking.  If you’re squeamish, you have to move fast to avoid staring at the inside of arteries, hands with amputated fingers, or throats with holes in them.

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.

By Philip Alcabes | June 27th, 2009 | Categories: Behavior, Disease, Health Professions, News, public health, Risk | Tags: , , , , | Comments Off on Iconography of Risk

Does Health Mean More Than Avoiding Risk?

If our society is going to be  healthy population it will mean making everyone healthy.  Self-evidently we’ll also have to think about what it means to be healthy.

Often, we do think about this – but usually by considering what the risks are and how to avoid them.  That means, we ask whether we can make life less harmful by changing something, and then we ask what change to make (and what it will cost).

Rarely do we ask: what sort of health do we expect – especially if we also have to accord that level of health to everyone?

There’s something about the risk question that goes against the concept of health for all.  Almost always, the risk we talk about pertains to us:  what can we affluent, educated people in the U.S. do to make sure we don’t get sick (or die) tomorrow? It’s not very often that we ask about risks for people who can’t get the recommended exercise or eat the recommended fruits and vegetables because they have kids and no job.  Not too often that we are concerned about the risks of medicating adolescents (see below) for people who can’t make such assessments because their kids are incarcerated.  When health = avoidance of risk, we mean “health for people like us.”

Not that the risk question is frivolous.  It gets particularly poignant when it comes to children.  For instance, Liz Borkowski posted a valuable note at The Pump Handle last week about the use of antipsychotic drugs for children.  She was commenting on a post by Alison Bass that was concerned with “shilling for Big Pharma,” about the death of a 12-year-old Florida boy who was on several medications.

Whether the world we’ve made is dangerous to our kids is a question that can’t be ignored.  But we also have to remember that it’s only one side of the story, and it’s only part of that one side (the part that pertains to people like us).

Often, we hear a plea for a deeper conversation about health.  It’s what we are hearing when parents of autistic children ask about vaccine safety, or others ask whether the prominence of the autism epidemic is going to translate into better treatment for autistic adults (as Karl Taro Greenfeld did in “Growing Old With Autism” in the NY Times, 23 May).

It’s what we are hearing when parents of troubled children allege that pediatric bipolar disorder is underdiagnosed or when others argue that it’s overdiagnosed.

These voices aren’t talking about risk; they’re speaking in a different register.  They’re talking about suffering, and the alleviation of suffering, and asking what sort of responsibility the society (or the state) is going to take.

Too often, we can only hear the risk part, not the alleviation-of-suffering part.  We react to the allegations that vaccines cause autism, for instance.  Some people are attracted by the lure of an easy-to-blame culprit (vaccines or other products of Big Pharma, immunization guidelines or other policies of Big Medicine) and join the bandwagon; others are repelled by the anti-immunizationists’ failure to venerate Big Science, and ridicule the parents who don’t want their kids vaccinated.  But not too many people interpret what they’re hearing as a cry for more caring, rather than a demand to identify risks.

In the health professions, we’re especially given to hearing such claims in terms of risk, rather than health-vs.-suffering.  For instance, we take notice when (as Sarah Rubinstein points out at WSJ Health Blog), the pharmaceutical industry talks about having a role in the conversation over the costs of health care  as the WSJ reported on 26 May.

But the reason we’re interested is often because we want to debate how to structure the healthcare industry rather than because we really want to discuss how much caring there should be in healthcare.

This isn’t a matter of idealism or some kind of touchy-feely hippie alternative to industrialized medicine.  It’s a real, and realistic question.  No rational person wants to give up effective medication for people who are suffering, or wants our society to stop doing research that would tell us if certain drugs might be harmful.  But to think only about the risks and not about the suffering part is to blind ourselves to the more difficult – and more essentially human – questions about health.

By Philip Alcabes | May 30th, 2009 | Categories: Disease, Health Professions, public health, Risk | Tags: , , , , , | Comments Off on Does Health Mean More Than Avoiding Risk?

Myth Making and Health: New York’s Health Commissioner Will Head CDC

New York’s health commissioner, Dr. Thomas Frieden, will be leaving town to become director of the federal Centers for Disease Control and Prevention in Atlanta.

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.

By Philip Alcabes | May 16th, 2009 | Categories: Behavior, Myths, public health, Risk | Tags: , , , , , , , | 1 comment

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