Qatar is the richest country in the world. As such, it provides a vivid demonstration that money can't buy you health any more than it can buy you love. The converse, in fact, appears to be true: The wealth of Qatar is being purchased at the cost of its people's health.
As I write this, I am at 36,000 feet, give or take, flying back to the United States from Qatar, a peninsula jutting out from Saudi Arabia into the Persian Gulf. I suspect most who read this will never have been to this part of the world. (I have been, once before, to Abu Dhabi for a meeting of a World Health Organization working group.) Even so, I am sure particular impressions ensue.
Of course, the name Persian Gulf inevitably invokes the suffix "war" for all of us who had the skin of kin and countrymen in that conflict. But while Kuwait and Iraq do indeed reside at the northern reach of the Persian Gulf, bordered to the east by Iran, Qatar is a considerable and safe distance to the south. Culturally, it is worlds away, and had no direct involvement in the Gulf War, or the regional conflicts that have followed.
Other impressions, less military, are no doubt as indelible. Thoughts turn to sand and sun; palm trees and the native dress of the desert; heat, and of course, oil. These do, indeed, abound.
But if our collective impressions of places like Qatar do not incorporate epidemic obesity and diabetes even more severe than in the United States, we are behind the times. For that is the very situation, and that's why I was there.
I was invited to Qatar by the branch of the Weil Cornell Medical Center (WCMC-Q) established there. Cornell University was, I am told, the first ever to offer the M.D. degree at a site outside the United States. Faculty and students alike are very international, but the degree conferred is identical to that of the parent institution in New York City.
At the invitation of my WCMC-Q colleagues in medicine and public health, I spoke at a symposium and met with officials of the Supreme Council of Health of Qatar. I was here to share knowledge and insights in my area of expertise, but I got an education as well.
I knew before that obesity and chronic disease rates were high and rising fast in this part of the world. Not having made a study of Qatar before, I did not know that the prevalence of diabetes there is roughly twice as great as in the United States, some 17 percent of the population as compared to our 8.3 percent. Given how often we speak of the United States as the veritable epicenter of the global obesity pandemic, I did not know that obesity prevalence was slightly but decisively higher in Qatar, at 40 percent, as is the overall prevalence of overweight and obesity at roughly 75 percent -- and the rate of childhood obesity.
Several things make this relevant to us all, and worthy of our collective attention.
First, the rapid rise of the very public health problems that bedevil the so-called West in a very different Middle-Eastern population highlight the extent to which vulnerability to these perils is universal. The perils of modern epidemiology are not national perils; they are human perils. As a species, we have no native defenses against the lure of the couch and caloric excess, and as a species, we succumb all too readily to both.
Second, the rapid development of these concerns in Qatar -- over a span of years, not decades -- indicates the potential folly of excessive focus on genetics or physiologic variation. It's true, some of us are more vulnerable than others to obesity and Type 2 diabetes alike. And it's true that genetic variation plays some part. But genes, hormones, and metabolic pathways have not changed in Qatar in a span of 10 or 20 years. Changes that did not occur cannot be the explanation for changes that did. For the salient causes of salient effects, we must look for corresponding change -- and we see it in the environment, and in culture.
Third, the recent advent of our home-grown epidemics some 7,000 miles away is a clear and compelling illustration of the power of culture, for the good or ill of health. When native culture and lifestyle prevailed here, there was little or no obesity. Foods were simple and close to nature, and physical activity was required for accessing water and managing animals.
Oil, and affluence, changed all of that. Qataris have the highest per capita income in the world. They have access to the world's food, and the world's technology. A diet limited to simple, wholesome, native foods and routine physical exertion are yesterday's news. Today's news is all about what happens when lifestyle runs off its traditional rails.
The one element intrinsic to our own fashion-focused culture that may help apply brakes to runaway obesity and diabetes is, for better or worse, our vanity. As I reflected with a colleague during our time in Qatar, most patients and dieters are motivated to address weight control less for health, and more because of what they see in the mirror. This is far from ideal, and brings its own baggage, from impaired self-esteem, to fad diets, to eating disorders. But even so, some reason for efforts to control weight may be better than no reason at all -- as evidenced by the trends in Qatar.
In Qatar, native dress for both women (the djelabia) and men (the thoub) is loose, gown-like, and quite comprehensive in its coverage. In such garb, obesity has to be rather severe before it is apparent to anyone -- perhaps even its owner.
Qatar, then, is in crisis. A crisis borne of native vulnerability and imported menace. A crisis much like our own, but playing out over an accelerated time scale.
Like all crises, this one harbors both danger and opportunity. The danger is clear enough. The opportunity is to introduce remedial programs and policies at a pace and scale commensurate with the threat. A small country of less than 2 million with a highly centralized authority, Qatar can, in theory at least, do this.
Here's an example. We know that a mere 20 minutes of physical activity five days a week can immunize high-risk children against diabetes. We know that a comparable dose of physical activity, in conjunction with a balanced, healthful diet, can prevent diabetes in nearly 60 percent of high-risk adults.
So imagine a cultural commitment at the highest level to making 20 to 30 minutes of daily physical activity the prevailing norm. The Supreme Council of Health in Qatar might convene all of the relevant stakeholders, and issue this mandate: Let's work together to accumulate those 20 to 30 minutes. How much can employers contribute? How much schools? How much parks and recreation, how much zoning, how much transportation?
We will forego the details -- those can wait for the actual work of such a panel. But perhaps you can glimpse, as I can, the opportunity for collective effort to reach the tally, and its attendant prizes. Representative groups of "average" citizens should join the effort to ensure that the dosing methods are at least widely acceptable, and at best downright appetizing. And once done for physical activity, much the same approach could be taken to enhancing the national diet.
Qatari culture, though, much like our own, looks at the sharing of indulgent food as a way of demonstrating generosity and love. Their culture, like our own, harbors considerable ambivalence at best about physical activity. After all, it was their affluence that permitted them the luxury of exercising less. Their culture, as ours, resists the regulation of lifestyle.
But in their culture, as in ours, parents love their children. Husbands love their wives. Siblings love their parents, and one another. And there, as here, the consequences of unhealthy living --heart disease, cancer, stroke, dementia, and diabetes above all -- have invaded almost every family.
So they, as we, must update their culture, and the way they show love -- or suffer the ever-worsening consequences.
Culture is of our own devising. Most of its features developed over long periods of time, and developed because they made sense. Bountiful food as love was rational when food was scarce. Bountiful food makes for very dubious new-age love, however, when it contributes to the need for insulin injections, or an ambulance ride to the CCU.
One of the great challenges for public health in the context of modern culture is to help make culture fully modern, and conducive to health. As the choices related to that challenge play out across the globe, years of life, and life in those years, will hang in the balance.
The Beatles famously told us that money can't buy us love. Qatar tells us it doesn't buy health, either.
There is, however, opportunity in the crisis of chronic disease in Qatar. There is opportunity in that crisis in the United States, and much of the world, as well. We can choose to make health at least as great a cultural priority as wealth, and invest in it -- rather than cashing it in for money we can't take with us when we go, and will be too sick to enjoy spending while we're here. We could be both healthy and wealthy, but only if we choose to be wise.
Dr. David L. Katz; www.davidkatzmd.com
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