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By Emily Friedman. First published in Hospitals & Health Networks Daily on December 4, 2012
New York City Mayor Michael Bloomberg is no stranger to controversy. But he may have set a new standard for polarizing people with his campaign to make unhealthy food — supersized soft drinks, sugary and starchy snacks, and other products — as unavailable to New Yorkers as possible. In doing so, he has become the touchstone for a national debate over how much pressure to adopt healthy lifestyles is too much.
Note: We are all aware of the calamity that Hurricane Sandy brought to the Eastern seaboard, especially New York and New Jersey. Obviously, Mayor Bloomberg has his hands full. However, he remains committed to his anti-sugary drink campaign, and I am addressing it with full knowledge that this is probably the furthest thing from New Yorkers' minds these days.
A colleague of mine, years ago, called it "public health fascism" — the predilection of those who promote healthy eating and living to point out, stigmatize, intimidate and seek to convert people who indulge in lifestyle practices of which the reformers take a dim view. The term is a bit extreme, but my colleague intended it to be so, in the interest of stirring debate.
Most recently, the roving eye of healthy living advocates has focused on food, specifically, very large helpings of sugary soft drinks (those sweetened with substances other than sugar are exempted, leaving one hoping that the Food and Drug Administration has adequately tested those sweeteners).
Foremost in the growing pack of enthusiasts is Mayor Michael Bloomberg of New York (first a Democrat, then a Republican, now an Independent), who has, among other campaigns, fought to improve the healthfulness of food served in city schools and at public and private hospitals. In May, he proposed a ban on the sale of oversized sugary drinks in many settings in the city. It was approved by the board of health in September. The city was promptly sued by the beverage industry, which has a very successful track record of stopping such measures.
The ban itself is a bit strange — and inconsistent. It prohibits the sale, at any one time, of more than 16 ounces of drinks sweetened with sugar, but exempts beverages with artificial sweeteners, beverages that contain more than 70 percent fruit juice or 50 percent milk, or that contain alcohol. The rule applies to restaurants, fast-food outlets, food carts, delicatessens, movie theaters and sports venues, but not groceries, including convenience stores. This obviously allows bodegas located near these other sites to try to pick up the slack.
The initiative was big news and provoked comment nationwide. At the Alfred E. Smith Memorial Dinner in October in New York (a charitable event at which, during election years, the presidential candidates are expected to attend and make fun of each other and themselves), President Obama cracked, "This is my last political campaign. I'm trying to drink it all in, but Mayor Bloomberg will only let me have 16 ounces." And on Nov. 1, after Bloomberg endorsed Obama over Republican Mitt Romney, libertarian U.S. Senator Rand Paul snapped, "I don't think many of us thought that nanny Bloomberg was going to be endorsing a Republican any time soon. We can't even get a decent-sized Coke to drink in New York City anymore."
This is not the first time a major public figure has drawn fire for taking strong measures to protect the health of society and individuals. Two years before being appointed secretary of health, education and welfare in 1977 (it was he who later changed the name of the agency to the Department of Health & Human Services), Joseph Califano quit smoking.
Aware of the 1964 surgeon general's groundbreaking report on tobacco, which stated in no uncertain terms that it was a health hazard, Califano in 1978 launched a war on smoking that at the time was unprecedented. He banned tobacco use in HHS buildings, installed preserved cancerous lungs in the lobby of the agency's headquarters building, and named cigarette smoking "public health enemy No. 1." He asked tobacco companies to donate part of their advertising budgets to messages urging children not to smoke, and argued that smoking cost the United States $17 billion to $25 billion annually in health care costs and lost worker productivity.
His efforts were not greeted with universal acclaim. Conservative columnist James J. Kilpatrick, himself a former smoker, in an ironic precursor to Rand Paul's remarks 34 years later, in 1978 described Califano as "the one great nanny of us all," and warned, "Auntie Joe probably will succeed in making the habit more attractive than ever. He is likely to trigger what used to be known in our house as the beans-in-your-nose reaction. This is the reaction of the impudent child who is ordered not to put beans in his nose — and can hardly wait until his mama's back is turned."
Kilpatrick added, "Smoking doubtless annoys and irritates many nonsmokers, though not all of them, and their rights and feelings have to be respected. But the world is full of annoyances and irritations, and some of these vexations, like paternalistic bureaucrats, are worse than the demon cigarette" (Chicago Tribune, Jan. 22, 1978).
Always a prickly character and not one to suffer fools gladly, Califano persisted in his campaign, among others (he also defended the rights of gays, not a highly popular position at the time). He was fired by President Jimmy Carter in August 1979. He went on to found the National Center on Addiction and Substance Abuse at Columbia University in New York, where he remains active.
However one feels about him, Joseph Califano can be assigned a large part of the credit for the subsequent decline in cigarette smoking in the United States; he was the first well-known figure to try to translate the surgeon general's report into action. And he tried to make smoking unfashionable, despite huge pressures in the opposite direction.
So the New York City soda debate is not unique; indeed, it is hardly the only contemporary example of controversial efforts seeking to improve the public's health, and sometimes that of the environment. The cities of Richmond and El Monte in California had measures on this year's November ballot charging a 1-cent-per-ounce tax on soft drinks. Both lost, but that will not stop other government entities from charging extra taxes on alcohol and sometimes on soda (Washington state does the latter, and other governments are exploring the idea).
As we all know, the FDA has required nutritional content labeling on most foods sold in stores for a while, and more recently ordered the same for restaurant menus and menu boards.
Cook County, Ill., seeking to fill a large budget hole, tried to implement a tax on bullets and firearms, but settled for a $25-per-weapon sales tax at gun and sporting goods stores. In an area with soaring rates of violence and murder, making the county dependent on revenue from both raised a few eyebrows, even among non-gun enthusiasts.
And in a move that could make many a junk food junkie's blood run cold, Rockford, Ill., has banned Flamin' Hot Cheetos, and schools in New Mexico, California and elsewhere are considering doing the same. One of the arguments is that the little crunchies are more or less addictive due to the manufacturer's manipulation of salt, fat and sugar content. The more common rationale is that they are really bad for you.
(I must be honest: I like a Cheeto now and then. But the flaming hot variety would sear the chrome off a toaster. I would be much more concerned about what all that hot chemical powder is doing to children's mouths, or, more important, to their upper respiratory systems; super-hot foods have been implicated in nasopharyngeal cancers.)
It isn't just human health, but also that of the earth, that advocates of such initiatives seek to protect. Around the world, nations are banning plastic bags, perhaps because their leaders (like the rest of us) are sick of seeing them wrapped around tree branches and electrical lines and clogging street drains.
In our country, entities as disparate as IKEA, Whole Foods and the cities of Los Angeles and San Francisco have banned the use of these bags. Other municipalities, including the District of Columbia and Montgomery County, Md., have instituted a 5-cent-per-bag tax. It certainly seems to have had the desired effect: In D.C., for example, monthly plastic bag use dropped from 22 million to 3 million. The ordinance also has produced $2 million in revenue. The Montgomery County tax produces $170,000 a month. The latest taxes on tobacco and guns in Cook County are expected to produce some $40 million in new revenues.
And there's the rub: Are these measures being approved to enhance health or a government's bottom line? The failed Richmond, Calif., soda tax was designed, according to Reuters news service, "to boost municipal coffers and fight obesity" (Reuters.com, Sept. 6, 2012).
If protecting the public's health is the main goal, then an outright ban would seem to be more logical. Yes, it would deposit some revenue from fines and penalties into municipal bank accounts, but, more likely, it would also greatly reduce usage. However, the District of Columbia plastic bag tax appears to have accomplished both objectives.
This is an important point, because the fact is that states and some municipalities have become addicted themselves — to revenue from "sin taxes." Gaming is now legal, to one degree or another, in most states and selected municipalities; these range from Gardena, Calif., to the entire state of Nevada. According to the American Gaming Association, it's a $93 billion a year industry. States run lotteries and gather taxes from horse tracks, bingo parlors, pari-mutuel betting establishments (which the states sometimes operate themselves) and casinos. Many political leaders are anxious to expand gaming because it produces so much revenue.
The new Cook County budget also hiked tobacco taxes by a dollar per pack of cigarettes. Most states benefited handsomely from the 1998 tobacco settlement, which poured and will pour millions of dollars into state coffers for years to come in compensation for health care costs and misleading marketing. However, not much of that money ever made it to the supposed primary uses: prevention of smoking and assistance to smokers who want to quit. In perhaps the most blatant move, Wisconsin sold its entire $5.9 billion, 25-year settlement kitty and used the money to plug a one-year budget deficit. Other states used their shares for all kinds of things, many of them not health-related. According to the Campaign for Tobacco-Free Kids, although states will collect $25.6 billion in settlement funds this year, only 1.8 percent will be spent on tobacco-related health promotion activities.
Taxes on tobacco and alcohol are old news; maybe they discourage use, or maybe they produce revenue, or, more likely, they do both. But now the new and wonderful world of recreational marijuana is opening up. "Medicinal" marijuana — the use of which has not always been, shall we say, tightly clinically controlled — is now legal in 17 states, including such "red" states as Alaska, Arizona and Montana (the color refers to Republican Party preference, not individual politics). In the November election, three states' ballots included measures legalizing small amounts of recreational marijuana — Colorado, Oregon and Washington. The Oregon measure failed, to the surprise of many; the other two passed.
Now we face the possibility of a rich new source of taxation: the devil weed. Given its widespread use (it is said to be the No. 1 cash crop in California and Hawaii), other initiatives can be expected. Opponents point out that it's bad for the lungs, that people who have smoked or otherwise ingested a lot of it don't know what they're doing (especially behind the wheel) and that legalizing marijuana is simply a camel's nose under the tent of illegal drugs, many of which are much more potent and dangerous, many of which are tied to violent illegal activity, and many of which can kill.
And that's not to mention the fact that under federal law, all marijuana use is illegal, which continues to give local (and will now give some state) officials fits, as they try to figure out how a commonsense detente might be reached.
(I always thought that Medicaid was the worst battleground of state-federal relations; this one could be even worse.)
But if the economy continues to suffer, and state and local government revenues remain insufficient, the lure of taxing marijuana could dwarf all opposition.
Meanwhile, back at the soda fountain (for those of you who remember such things), it would be difficult to counter claims that obesity is an epidemic in this country. A recent survey by the Trust for America's Health and the Robert Wood Johnson Foundation reported that by 2030, the nation will spend between $48 billion and $66 billion on treating preventable obesity-related conditions. That year, 13 states could have obesity rates higher than 60 percent, 39 states could have rates above 50 percent, and all 50 states would have rates higher than 44 percent. Mississippi would be highest, at 66.7 percent; but even the state with the lowest rate, Colorado, would be at 44.8 percent. And now that recreational marijuana is legal there, chronic attacks of munchies could up that percentage.
Seriously, obesity is obviously a public health problem. Obese people are far more prone to diabetes, heart disease and other conditions, and their very weight makes it difficult for them to engage in fitness activities that might counter it. Hip and knee joints are more stressed, feet suffer and even difficult skin conditions can develop.
No one denies these facts — at least, I hope no one does. The zillion-dollar question is, what works to counter obesity and poor diet? Taxation? Bans? Punitive approaches or encouraging ones? Should overweight people be treated with support and sympathy or ostracized? We have tried, and are trying, everything. But what works?
One approach that has not been given sufficient scrutiny is to take a broader view of the issue. In some cases, there seems to be a genetic component; certain racial and ethnic subgroups appear predisposed to putting on weight. Also, culture plays a huge role — as so many pundits have observed (I don't know the origin of the statement), culture trumps policy. It also trumps strategy. You may not like it, but Spam (the food kind, not the computer kind) is an ingrained staple of the Hawaiian diet; deep-fried food is a longtime feature of Southern cooking; salty pickles and corned beef are Jewish soul food; and it's rare to find a Southeast Asian table without a bottle of fish sauce, which is basically liquid salt.
Availability of affordable, healthy food is no minor issue, either. Although the stereotype is common enough — the obese are poor, non-white, nonworking slobs who eat only fast food and won't help themselves — it is not only hogwash, but also racist. I will always remember asking one of the vendors at my local farmers market if ours was the busiest; he laughed and said that no, the busiest ones were in disadvantaged minority areas of our city, where customers were waiting when the markets opened at 7 a.m. and the vendors were cleaned out by noon.
People eat salty, sugary, caloric foods for a variety of reasons, which range from the fact that they taste and smell good to the fact that in an era of skyrocketing food prices, they're somewhat affordable, to the fact that they may be the only conveniently available edibles. If you're a working single mom, living paycheck to paycheck, with a couple of kids, salmon steaks grilled with lemon and vegetables are out of reach on a number of levels.
And, I would point out, there are millions of people who were never taught how to cook in the first place. For me, it's a hobby; but I know altogether too many people who don't know how to boil an egg (which, if you're making soft-boiled eggs, can be surprisingly tricky).
It is no surprise, then, that a wide spectrum of approaches to reduce obesity, especially in the young, is being attempted. First lady Michelle Obama, herself a fitness enthusiast, has launched the Let's Move campaign, which emphasizes regular modest exercise and healthy food choices. She also hosts vegetable growing at the White House, as do many community gardens and botanical gardens. The Chicago Botanic Garden has a program through which inner-city schoolchildren learn about vegetables and harvest the fruits (and veggies) of their labors. More and more restaurants are becoming customers of garden projects. Even the notorious Cabrini Green public housing project in Chicago, birthplace of many a gang, also became the birthplace of freelance gardens, whose produce was purchased by some of the finest restaurants in the city.
Interestingly, the first lady's efforts scored as "most effective" in a recent survey conducted by researchers at Yale University. Their findings overall were that "the public craves positive reinforcement and rejects stigmatizing or other negative messages."
That hasn't stopped some health care organizations from pursuing a tough — indeed, a very tough — approach. Children's Healthcare of Atlanta launched a series of print and video ads that attack everything from denial to obese people themselves. Among the myths it challenges: "It's just baby fat; he'll grow out of it." "The whole family's built like this. And we're fine." "Between work, day care and practice, you have to fit dinner in somehow." "You don't know how she is if she doesn't get her way."
Most troubling to me were some of the print ads, notably this one:
Source: Children's Healthcare of Atlanta
I couldn't help wondering how this little girl (and she is one, the ad notwithstanding) felt as she was posing for this ad.
Blue Cross and Blue Shield of Minnesota's television ad campaign isn't quite so stigmatizing, but it still packs a wallop. One ad shows a little girl loading up her miniature grocery cart with unhealthy food, while her mother looks at her own cart and sees that the child is imitating her. Another features two kids in a fast-food restaurant bragging about how much their fathers can eat, with one saying, "Maybe someday I'll be able to eat twice that much." The father of one of them appears, holding a tray laden with fatty food. In these scenarios, parents are the villains.
Whether these campaigns have a significant effect remains to be seen; the stigmatization and marginalization of the obese, however, is clear. Indeed, one comment on the Minnesota ad campaign read, "I think the government should now focus on obese people and stop bothering smokers — they have already been demonized enough." Great; like rats in a cage, the marginalized can now eat each other alive, with society's blessing. Obesity can give smokers someone to whom to feel superior.
The end point of the hardball approach was envisioned by Massachusetts Institute of Technology professor Jonathan Gruber, who suggested that "Ultimately, what may be needed to address the obesity problem are direct taxes on body weight." He explains that insurers are already allowed to discriminate against the obese (and smokers), and that the Affordable Care Act allows this practice up to a premium differential of 30 or even 50 percent.
It seems to me that such a tax — and perhaps even such insurance discrimination, if it becomes widely known — would be enough of an affront to individual rights in a society that cherishes them to send many nonsmoking, non-obese people to the streets to man the barricades; that is, if they aren't busy defending themselves against accusations that they cost society billions in health care expenditures with knees ruined by jogging, heart disease caused by caffeine and overwork, and stress-related conditions.
But they won't be. What has bothered me from the beginning about the healthy habits campaigns is that they are selective. Alcohol, which causes a great deal of disease and heartache, is largely ignored unless one overindulges and then takes the wheel of a vehicle. There are passing gestures to help problem gamblers, but they are hardly deeply felt; indeed, the popular phrase is "degenerate gambler" (and pedophiles aren't? Oh, never mind.). People addicted to illegal drugs are marginalized, but those feeding compulsively at the trough of pharmaceutical antidepressants, stimulants, opiates and other psychotropic drugs — many of them addictive, hepatotoxic and unnecessary — are treated with great sympathy.
Even within an addicted group, there are delineations. A homeless street person with an alcohol or drug problem is a street drunk or a junkie; a movie star with the same problems gets pass after pass after pass, even from the criminal justice system. (Yes, I am thinking of Lindsay Lohan and many other celebs who kept on and keep on getting away with it. Problem is, many of them are dead as a result, because no one ever told them to stop, and there were few, if any, consequences if they didn't, until the Ultimate Consequence came calling. Thus did we lose John Belushi, Jimi Hendrix, Billie Holiday, Michael Jackson, Janis Joplin, Charlie Parker, River Phoenix, Elvis Presley — a long and tragic list that only gets longer.)
In other words, do you think Passages Malibu accepts Medicaid beneficiaries? Somehow, I think not.
Furthermore, some people — and this was true of many of the bright creative lights that have gone dark — resist being told what to do. They're rebels. As Rebecca Puhl, Ph.D., director of research and weight stigma initiatives at Yale University, has observed, "By stigmatizing obesity or individuals struggling with their weight, campaigns can alienate the audience they intend to motivate and hinder the behaviors they intend to encourage." That applies to more than obesity.
My other concern with these initiatives is that they have unintended consequences, sometimes brutal ones. The Prohibition Era (1920-33), born out of a sincere attempt to end the use of what was viewed as a toxic substance, did reduce legal drinking. It also gave us Al Capone and organized crime, which rode to glory on the profits of illegal booze, and the extremely nasty jake leg poisoning epidemic (see "Happy Tails, Jake Leg, and the Food and Drug Administration" on my website, published in H&HN Daily, Aug. 7, 2007.
John P. Morgan, M.D., who brought the modern medical world's attention to the jake leg tragedy in several brilliant articles, by 1995 had concluded that prohibitions on the use of substances that people really like do more harm than good. He cited the inevitable rise of shadow and black markets, accompanying illegal activity, alteration of banned substances with adulterants that are often poisonous and even fatal (with no regulatory oversight, of course), uneven potency (as we have seen with street heroin) and marginalization of users, which makes it easier to write them off when they are harmed.
"The Jake victims," he wrote, "were derided and laughed at. It was widely held that they deserved what happened to them, as did thousands of blinded methanol drinkers. It is not enough to state that the laws of prohibition produce excluded, marginal humans. In the United States, it is clear that the marginalization of a group of despised people is the goal of the policy … . An oppressive government denies to individual citizens the right to control their bodies, and then despises them for harm done, not by the substance, but by its contaminated, poor-quality version generated by those laws. It is of no surprise that those poisoned by Jake [and other adulterants in illegal substances] were given little sympathy and little consideration."
I didn't agree with Dr. Morgan, who is, unfortunately, deceased. He was a fine researcher and I learned a great deal from him. But whether one agrees with him or not, a pattern's a pattern, and his thoughts are worth considering as we continue to careen — taking few, if any prisoners — down the road toward perfect health habits and immortality, neither of which, unfortunately, is possible.
At least, I hope that the future will not feature a few pariahs standing around outside the office buildings where they work, furtively sneaking 32-ounce Cokes and Cheetos. But it may well.Copyright © 2012 by Emily Friedman. All rights reserved.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express. The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.
First published in Hospitals & Health Networks Daily on October 2, 2012
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