We might, I suppose, hold all victims of Hurricane Sandy, or the recent blizzard in New England, or Hurricane Katrina responsible for the various ills that befell them. For whatever it's worth, my family is in this group; we suffered some consequences of both Sandy and the blizzard.
We might assert that if their houses were washed away, they had houses in the wrong place. If they lost power and suffered for it, they failed to install suitable generators in advance. And if these or other natural disasters resulted in injury, ill health, or even death -- those, too, might be attributed to some deficit in preparation. We might assign all of the consequences to some chink in the armor of personal responsibility.
But thankfully, we don't. We recognize that some exposures are simply bigger than any individual. We accept that some forces can overtake and overwhelm us. We accept that we can be responsible people, and still not be responsible for everything. That's a good start.
Epidemic obesity and chronic disease is, like a perfect storm, the product of massive and protean forces. It is an emergency in slow motion, but an emergency just the same. Whereas a hurricane devastates one part of our country over the span of a few days, obesity and attendant chronic disease have been battering at our entire population over a span of decades. The consequences are concisely epitomized by noting that what was "adult-onset" diabetes less than a generation ago is now routinely diagnosed in children under age 10. Other chronic diseases -- heart disease, stroke, and cancer -- are following diabetes down the age curve.
Like any other storm, these threats call for a brisk and well-coordinated crisis response that has yet to materialize fully. Instead, as our bodies expand and our health deteriorates, the body politic has divided into opposing camps claiming personal responsibility, or environmental factors, as the mutually exclusive explanations for our plight. Such polarity translates into partial paralysis, forestalling the cooperative actions needed to curtail this relentless scourge.
The ideological impasse naturally owes something to politics. In 2005, the U.S. House of Representatives passed HR 554, the "Personal Responsibility in Food Consumption Act," sponsored by Rep. Ric Keller (R-Fla.), intended to prevent "frivolous" lawsuits that hold food companies liable for an individual's obesity and related health claims. The bill, which never passed the Senate, contends that one "cannot litigate personal choices and lifestyles," and was applauded at the time by the National Restaurant Association.
The opposing view, that an "obesigenic" environment trumps personal choice, tends to prevail among public health advocates, and with good reason. In 2005 and 2006, the Chicago Tribune highlighted food industry practices, including the use of functional MRI scans of the brain, to determine flavor combinations most conducive to endless eating. An updated overview of food industry efforts underlying the addictiveness of snack foods is the most recent New York Times Magazine cover story. The links between industrial profits and prevailing pandemics is elaborated in a current issue of The Lancet, a prestigious international medical journal.
But such arguments may get caught up in their own inertia, and go too far. In the movie Super Size Me, for example, not only was the potentially adverse influence of McDonald's food on health highlighted, but so was an exaggerated variety of individual helplessness. One interview in the movie features a man whose last resort for obesity management is gastric bypass surgery. But his obesity is ascribed to the consumption of nearly four gallons of soda a day! That he might have cut back to, say, three gallons was not addressed. There would seem to be some opportunity for personal responsibility in that scenario, as there is when choosing coat and footwear in a blizzard.
Realistically, we must invoke both environmental reform and personal responsibility to promote health. After all, if in our enthusiasm for environmental determinism we renounce personal responsibility altogether, we risk both ineffectiveness and irrelevance for failing to consider that you can lead people to carrot juice but you can't make them drink -- any more than you can make them use stairs instead of elevators, rakes instead of leaf blowers, or soccer balls rather than video games.
On the other hand, any fair-minded person must recognize that the playing field of opportunity for weight control is not level. Implying that people struggling with poverty, unsafe neighborhoods, and resource-poor environments are personally "responsible" for their weight can be the literal addition of insult to injury, a blame-the-victim mentality that ignores access, affordability, and social privilege.
The time to argue over evacuation routes is before, not after, floodwaters reach your door. We need a middle path toward common, higher ground now -- before we're all in over our heads.
What we need, and have thus far mostly failed to pursue, is a diligent attempt to base policies on data rather than reciprocal disparagements. Questionnaires can test what behavioral science calls "self-efficacy," the capacity to take personal control. Who does, and who does not, have the knowledge, skills, and resources to compensate for the obesigenic modern environment? We can, and should, find out, and devise means of providing personal control and empowerment where they're lacking, making environmental changes -- such as the elimination of junk foods from schools, or the addition of sidewalks to a suburban neighborhood -- where necessary.
Calamitous storms give us all a vivid demonstration of what failure to develop a prudent crisis response can cost. Like such storms, epidemic obesity and chronic disease are a storm perfectly suited to breech our meager defenses -- and in a veritable flood of tasty calories and labor-saving technologies, they have. And potentially all Americans are living below the level of this threatening sea.
To rise above the floodwaters of this crisis will require a blend of bold actions by those in power, and empowerment of those we ask to take responsibility for themselves. At some point, the interaction of environment and behavior does come down to choice, and we can ask individuals to make good ones -- just as we can ask them to make personal preparations for a dangerous storm. But the levees will remain our collective responsibility.
-The PRH Chronicles will continue...
For more by David Katz, M.D., click here.
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