A Big Fat Crisis (18 page)

An Alternate Vision

8

A Plea for Change: We Are All in This Together

Today, the whole world is facing a health crisis not unlike the one humanity faced in the nineteenth century, when industrialization and urbanization led to the increased transmission of infectious diseases, which were the major causes of death. Government action stopped the infectious disease epidemics then, and I believe government actions will be necessary to stop obesity and related chronic diseases now, using the same public health principles that address environmental risks rather than individual behaviors.

In the early 1800s, typical English urban households deposited all their trash and waste, including excrement, on the land adjoining their dwellings and shops. The garbage accumulated on sidewalks and in alleys, often overflowing onto the city streets, until hired scavengers or dustbin men carted it away. Large drains were built for storm water to prevent flooding, but all kinds of debris flowed through these channels, clogging them with feces, animal carcasses, and other refuse. Waste frequently pooled in the streets and backed up into people’s cellars and homes. Conditions were even worse in poor neighborhoods, where people did not have proper houses or easy access to water, which had to be obtained from local pumps.
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In crowded cities like London, epidemics of infectious diseases like cholera and typhoid flourished and were the leading causes of death. One-third of children under the age of five did not survive, and few lived past the age of forty.
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No one understood the exact mechanism by which these diseases were spreading. The dominant belief was that the decaying filth on the ground contaminated the air, which in turn infected people through invisible toxic fumes called miasma.
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Even though the science was flawed, a solution soon emerged: a British bureaucrat named Edwin Chadwick suggested that removing waste from densely populated urban areas would curb epidemics like cholera. (In case you think that Chadwick’s motive was pure, he proposed this because he did not want to spend the public’s money on providing food to the hungry, arguing that hunger should inspire people to work harder. But that’s another story.)

Chadwick’s suggestion to fight filth was met with great opposition. Although some preferred to spend public money to feed the poor rather than build sewage pipes, the loudest opponents didn’t want to spend anything, and argued that the expense associated with waste removal was too large. Others said there was no proof that removing waste would actually work. Why incur such an expense if there is no assurance of benefits? Still others worried about the scavengers who made their living from carting away refuse and excrement from the streets: what would happen to their livelihoods?

In an 1849 letter published in the
Times
of London, an outraged citizen declared,

    
We prefer to take our chance with cholera and the rest than be bullied into health. There is nothing a man hates so much as being cleansed against his will, or having his floors swept, his walls whitewashed, his pet dung heaps cleared away, or his thatch forced to give way to slate, all at the command of a sort of sanitary bombaliff. It is a positive fact that many have died of a good washing.

Despite these objections, several forces—including self-interested industrialists, fishermen, and farmers—ultimately pushed through sanitary measures that would remove waste and provide clean water. The sanitary movement spawned public health departments and an extensive
infrastructure to enforce regulations promoting hygienic conditions in homes, factories, and communities. The result was the virtual disappearance of cholera and typhoid, a reduction in a host of waterborne infectious diseases, and the assurance that nearly all babies born healthy would survive to adulthood.

Public health is the field of medicine that shouts, “We are all in this together!” Public health policies are intended to level the playing field so that we can all live in conditions in which we can be healthy. Public health is what makes sure that our environment doesn’t harm us—from the design of cars to the conditions at the workplace. But public health has been falling down on the job when it comes to chronic diseases.

It’s time to play catch-up.

Hardwired cognitive limitations make it nearly impossible for most of us to consistently resist overeating (or to spontaneously engage in physical activity), so ending the obesity epidemic will require changing the food and activity environments or changing ourselves. It is unlikely that human nature is going to change anytime soon, which is why I firmly believe that the best way to tackle the obesity epidemic is by creating a more balanced environment in which individuals can automatically make healthy decisions about when, what, and how much to eat (or exercise). The quickest and most efficient way to do that is through new public health regulations.

Our lives depend on regulations that protect us from pollution, dangerous building and marketing practices, charlatans, and hucksters. In all industries, in all worksites, and for all consumer goods, we have accepted the role of government to discourage practices that increase the risk of unhealthy outcomes, be it unintended injury or long-term disabling disease. We no longer tolerate needless exposures to toxins, unnecessary risks of injury on the job, or the marketing of harmful or defective products without substantial warnings or oversight.

Yet calls for change and more regulation always encounter resistance, especially among those who are profiting massively from the current conditions. The beneficiaries of the current situation argue that their right to sell whatever they want, however they want, is a matter of personal liberty—that it is up to individuals to make better choices if they really care about their health.

Yet these kinds of arguments do not fly in other areas, like the auto
industry. Today seat belts and air bags are not optional features; automakers must install them and ensure their cars meet safety standards. Would anyone seriously defend automakers who sold cars that didn’t meet safety standards by claiming it as a matter of personal liberty?

The defenders of the status quo count on the fact that most people are ignorant of how they are being influenced and believe that their choices are completely independent. Furthermore, many cannot see behind or beyond the current conditions, and assume these conditions are natural, normal, and/or reflect the common will. Many cannot see the hidden forces that undermine individual goals.

Yet there are ample historical precedents of success in changing societal perspectives on human behavior and regulating business practices that were previously considered immutable. The Sanitary Revolution, initiated in England in 1848, heralded the onset of changes of such an enormous magnitude that it dwarfs everything proposed herein. From the early to the late nineteenth century, perspectives on poverty and starvation changed dramatically, and societies went from having virtually no laws addressing environmental conditions to having a host of regulations governing water and sanitation, housing, food, worksites, and air quality.

In the early 1800s, England had “poor laws” that required local towns to provide medical care and medicine to people who did not have the means to pay for it (similar to federal mandates to provide emergency care at hospitals receiving federal funds). But medical officers often diagnosed “hunger” as the source of debilitation and prescribed food as the remedy. Many of the British, including Edwin Chadwick, who served as secretary of the Poor Law Commission and is the person most strongly linked with the Sanitary Revolution, called the practice of prescribing food instead of medicine “mutton medicine,” and considered it completely unacceptable.
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Chadwick’s major objection was that public subsidies of the basic necessities would encourage malingering and bankrupt local jurisdictions that were already feeling the financial pinch of having to provide living accommodations for the poor in workhouses. He believed that hunger should inspire people to work harder. As a consequence, he became the prime architect of new poor laws that not only banned
“mutton medicine” but also purposefully worsened the conditions in workhouses to discourage the poor from using them.
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Furthermore, Chadwick could not believe that the food allowances given by workhouses were so inadequate that people were dying from hunger.
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He thought that as long as people were truly hungry and had any possessions, they could always exchange them for food or take advantage of the workhouse safety net, and thus avoid starvation. (Today’s belief that people who want to avoid obesity really could be successful if they tried hard enough echoes the nineteenth-century sentiment that anyone who was hungry should have been able to find a way to survive with the meager assistance available to them.)

At the time there was no convincing scientific evidence that malnutrition could be debilitating, or that it could increase susceptibility to other diseases and make it difficult for people to work, so it was easy to spin stories about the poor being lazy or of dubious character that were congruent with favored political philosophies and religious beliefs. Yet because there were such high death rates among the working poor, which left entire families destitute, Chadwick latched on to the idea that the major cause of death in the 1830s was filth rather than hunger. He thought the government would ultimately save more money and avoid promoting malingering if it did something about disease-causing filth and contaminated air rather than increase the poor’s food rations or wages.

The absence of a sanitation system was indeed highly conducive to epidemics of infectious diseases.
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In the early 1800s, no one knew about bacteria; germ theory was not confirmed until the late 1860s. Nevertheless, Chadwick’s suggestion to remove wastes from densely populated urban areas was exactly what was needed to curb epidemics like cholera.

These vast, transformative changes in public health in Britain and subsequently adopted in the United States were not merely the gift of a central government that, in its munificence, passed enlightened legislation. In fact, in many cases, changes in sanitation at the local level were forced by lawsuits and injunctions or by the pressures from industrialists who needed pure water for their factories. In other cases, changes were implemented at the local level to support local needs
and priorities, and were often the result of the cooperation, competence, and foresight of elected members and appointed officials of local governments.
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Sewerage systems were introduced in some British towns after private parties sued localities to halt the pollution of rivers. These actions were won by appealing to English common law rather than public health laws. Successful lawsuits often resulted in a writ of sequestration, which either forced the town to allocate funds to provide a remedy or allowed the winning party to build the necessary sewerage works at the town’s expense.
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The force of law was substantial because failure to provide the necessary funds could lead to the seizure of the personal property and real estate of the mayor, aldermen, and burgesses of the borough.
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In most of the nineteenth century debtors were jailed, so being held liable spelled ruination.

Another prominent driving force of technological innovations in sanitary systems was industrialists, especially the proprietors of textile works, who needed pure, soft water in the manufacturing process of yarns and fabrics. The need for soft water was tied to the livelihoods and prosperity of the towns and in many cases led to the municipalization of the local waterworks. In this way, the community ended up supporting the high costs of clean water that was largely used by industry. Indeed, many of those on local boards who made these decisions were stockholders and/or had financial interests in the waterworks.

The cost of re-engineering a city or town that had been established for centuries was unprecedented and often equaled or exceeded the net worth of the entire jurisdiction. However, in England, infrastructure improvements were financed by government bonds, sometimes with a payback period of sixty years.
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In the United States, given that the country was relatively young, with growing towns and cities, there was perhaps less need for re-engineering and more for construction that incorporated the new sanitary principles.

Originally, sewers were built as unconnected drains intended to affect only a small surface area, not to service an entire city.
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The challenge was to join the pipes and get all the waste to flow steadily to a destination away from the city where it could be recycled and purified.
Because no one had any experience with how to build a sewerage system—how wide the pipes should be, how steep they should be laid, and how deep—the development of such systems was essentially a series of experiments. Designs were continually revised and upgraded when the pipes broke, clogged, or failed to operate as planned. The right answer was not immediately discovered, and it took decades to figure out how to create systems that worked efficiently and effectively.

Local authorities frequently resisted sanitary reforms. They did not want to sacrifice local autonomy or waste the taxpayers’ dollars on matters that were considered a concern of individuals. Many officials were afraid of taking the wrong steps because they were bewildered by the technical requirements and legal complexities. They had no assurance that the sewerage systems proposed would be sound or would improve the current conditions. Determining the best methods for sewerage systems was quite contentious, with multiple legal challenges in England.