A Big Fat Crisis (31 page)

A Manifesto Claiming Victimhood? Is There No Role for Personal Responsibility?

Personal responsibility is always the ultimate determinant of people’s behavior; even with the best social and environmental conditions, there are some individuals who manage to get into trouble. And of course, given the worst conditions, there will be some with the capacity to triumph—but they will be the exception. Nevertheless, in a free society, it is not the role of government to strictly regulate people’s behavior. But if people find it too difficult to achieve their goals or to stay healthy even after repeated attempts, it is a societal role to address the environmental conditions that undermine or interfere with their well-being. If 96 percent of the water is not potable, you can bet that a lot of people will be getting waterborne diseases. If most restaurants, supermarkets, and advertisements primarily encourage the consumption of foods that increase the risk of chronic diseases, we should anticipate that a lot of people will get sick.

Are we victims? Definitions of “victim” include a person who is harmed by or made to suffer from an act, circumstance, agency, or condition; one who suffers injury, loss, or death as a result of a voluntary undertaking (e.g., a victim of your own scheming); one who is tricked, swindled, or taken advantage of (e.g., a victim of misplaced confidence). We are victims of our own DNA, the forceful strategies
of marketers, and an affluent society with more than enough to go around. In the end, it doesn’t matter whether we blame human nature, the aggressive nature of the food industry, or our wildly successful systems of food production and distribution. People are suffering, and thus need protection.

Going Up Against the Food Industry

There is no doubt that the food industry will fight any regulatory changes tooth and nail. Its advocates will invoke the typical complaints: The government should not interfere in the marketplace. Individuals know best and we don’t need any “nannies.” Regulation will cause the food industry to lose money, which will prompt layoffs and increase unemployment. The economy will crash and farmers will go broke. Food isn’t the problem behind obesity; it is the lack of physical activity.

The food industry will bring all its resources to bear to forestall any action that will protect consumers, as did the tobacco industry in the struggle to regulate tobacco and stop the epidemics of lung disease, cancer, and heart disease that smoking caused.

Nevertheless, public health advocates were able to make a dramatic dent in smoking rates by addressing how, when, and where tobacco is advertised, priced, and sold; thus we should be able to tackle obesity. But more people have to be convinced that food environments are the main concerns. Once we have the correct targets in our crosshairs, there should be no stopping progress. We must move forward to protect our friends and families from exposures that threaten our health and well-being.

I have made many suggestions, though I am the first to admit that there is no existing proof that these new policies will work. But there is also no reason to expect that the obesity epidemic will spontaneously resolve itself. We must try something new.

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Conclusion

In the hot days of the summer of 1972, the New York City Health Department investigated an unusually high incidence of deaths among toddlers who fell out of tenement windows.
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Initially mothers and caregivers were blamed for not being alert, not properly supervising children, or simply neglecting naturally curious toddlers and adventurous young children who leaned out of apartment windows or crawled onto fire escape stairwells to cool off.

After an investigation, the Health Department launched a campaign, “Children Can’t Fly,” and offered free window guards to families in tenement buildings. The next summer, there were no falls from buildings that had the new window guards. Subsequently, despite a protest from landlords, the requirement for these $3 devices was added to the city’s health code. One landlord filed suit against the city, claiming the regulation was unconstitutional on the grounds that the new health code shifted the obligation for the care and protection of children from parents to the real estate industry.
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He lost.

The story of the “Children Can’t Fly” campaign is an apt analogy for the problem and the solution to the obesity epidemic. Children are born curious and may wander to an open window even if (or because) we tell them to stay away. All of us were born with the capacity and inclination to eat more than we need. In a world where there is too
much food, we have no constraints that limit our natural tendencies to eat what is readily available.

In the case of the open tenement windows, if we simply blamed the families and didn’t hold the landlords accountable, children would still be falling to their deaths. And similarly, in the case of obesity, restaurateurs and purveyors of food need to be held responsible for what they serve. The amount of food we eat depends on the conditions in which it is served and sold. If the food industry wasn’t selling us so much food that makes us sick, we wouldn’t be sick. Together, as a society, we have the power to change the conditions that favor overconsumption—for our own protection and preservation.

The public health experience is that blaming people for their own problems rarely yields any fruitful solutions. Indeed, throughout history, the lack of self-control has been blamed for nearly every poor health behavior and human failure—alcoholism, smoking, sexually transmitted diseases, injuries, and car crashes.

One approach to addressing these societal ills is to focus on individuals and to motivate them to change through either incentives, negative consequences, or education. In contrast, the public health approach usually focuses on the conditions in which people live and seeks to address the upstream forces that lead individuals to behave the way they do. For example, public health approaches to alcoholism, smoking, sexually transmitted diseases, injuries, and car crashes are not to punish, incentivize, or educate people, but rather to regulate alcohol and tobacco availability; give sex partners prophylactic treatment; and make products, cars, and roads safer.

In the nineteenth century, before germ theory was understood and bacteria and viruses were discovered, poor health behaviors, moral turpitude, the lack of discipline, and even belonging to certain racial or ethnic groups (inherited genetic defects) were cited as the causes of diseases like tuberculosis, cholera, and smallpox. Blaming individuals for their own health problems also fit in with prevailing religious views that God was simply meting out consequences for bad behavior. Individual responsibility has often been the default position when we don’t really understand what is going on.

Yet the great advances in public health have all occurred when
entire societies took monumental steps to change the conditions in which people lived. Regulations that mandated standards for sewerage systems, housing, working conditions, food storage and preparation, and air and water quality were not timid, incremental steps. These regulations were bold leaps whose impacts have extended our lives and reduced untold human miseries suffered by populations a century ago. We no longer have exceptionally high rates of occupational injuries, with workers falling into rendering tanks or becoming ground meat, as muckraker Upton Sinclair described in
The Jungle
, his 1906 book about the meatpacking industry. Nor do we have the level of industrial pollution associated with the London smog that killed between four thousand and twelve thousand people in five days in December 1952 and sickened more than one hundred thousand others. We can thank regulations, rather than the voluntary behavioral improvements of otherwise motivated individuals, for these healthier living conditions.

Our view of the responsibilities of societies and individuals has changed dramatically over the past century. Today, we expect our government to ensure that the air we breathe and the water we drink will not make us sick. We expect the government to make sure that housing and buildings will be constructed according to a rigorous code and won’t be defective or crumple in storms. We expect our government to make sure we are treated fairly at work and that conditions in the workplace are safe. We expect the government to ensure that transportation is safe, to protect us from terrorists in the air, and to prevent bridges from collapsing and trains from crashing. Moreover, we demand that the government test the safety of consumer goods and curtail false and misleading advertising.

The government’s role in monitoring the risks that individuals cannot easily protect themselves against is continually expanding. Our increasing demands on government are paralleled by our decreasing expectations of what individuals can effectively be responsible for. Everything has become so specialized and sophisticated that it is impossible for a single person to master it all. We expect the government to assume responsibility for what individuals cannot do to protect and promote their own welfare. In general, the populace has mostly welcomed these protections.

It is true that many regulations today seem to be arbitrary or over-the-top, and certainly we don’t need any more of those. Yet what now seem like reasonable demands to remove animal carcasses from the streets, and to clean human and animal wastes from the public byways, and not to sell alcohol to children, seemed like arbitrary and unjust impositions in the nineteenth century.

Coming to terms with the host of regulations I have proposed is not going to be easy. I have great sympathy for complaints against a government that seems as if it already has too many onerous and unreasonable regulations now that I am trying to build my dream cottage in the middle of a rural area. I have had to face and comply with what seems like a host of burdensome requirements by the County Department of Building and Safety. The house I am planning is relatively small, with a thirty-by-forty-foot footprint, yet I need to get a zoning clearance, a soils test, a flood permit, a grading and earth removal permit, a permit for a septic tank, a well permit, a water quality permit, a permit for electricity, a building permit, a traffic permit, an integrated waste management permit, and a fire permit. I must hire several licensed professionals—an architect, a structural engineer, a soils engineer—to sign off on my plans. I need twenty-two separate documents, and I have to pay at least twelve different fees, including a traffic mitigation fee, a fire protection fee, a school district fee, an acreage assessment fee, a flood hazard clearance fee, and fees for seven different departments to check and approve my plans. Personnel have to come to the building site at every step along the way to approve the progress. They insist on personally checking that all the construction follows the building code.

I have had to change my plans dramatically and spend way more than I planned because of these building codes, which were presumably created for my benefit. Today, all new buildings in California must be equipped with fire sprinklers. Even though I must include them, I also have to build my house within 150 feet of the public street so a fire truck can reach it in case of emergency. Although I wanted to build the house as far from the road as possible to have more privacy and peace and quiet, approval would have required paving a road strong enough to bear a sixteen-ton fire truck and wide enough for it to turn around. This would have been unaffordable, and it would have also defeated
the purpose of moving to a rural area, which was to avoid a lot of asphalt and cement.

Not only are there multiple permits, but the specialists checking all the details of the building process also seem to have obsessive-compulsive disorder. We have had to go back and forth multiple times with multiple departments to specify everything on the plans. We have to state the location of all the valves and pipes and indicate each pipe’s diameter. We have to locate a hydrant not less than a hundred feet from the house. We have to specify the depth of the foundation and the height of the electric panel. And the land around the house has to have at least a 2 percent slope away from the house for proper drainage.

What is the public health impact of such rigid, extensive, and meticulously specified building code regulations? A poor-quality house would pose a danger to relatively few people—just my husband, any guests we might have, and me. So much attention to such a small project hardly seems worthwhile (except that it appears that our permit fees are the way government bureaucrats get paid).

Although there are some quirky requirements that appear not to make sense and the extra cost of the permits and inspections is quite burdensome, the truth is that I very much appreciate that the county is checking to make sure my new home will be sound. I have no expertise and would otherwise have to rely on the builder. Having someone else’s eyes on the plans increases my confidence that I am making a good investment in a house that will be able to withstand earthquakes, floods, and other problems that may arise.

Compare the massive amount of regulation I face to build a small bungalow with minimal impact to the minimal regulation of food outlets like restaurants and grocery stores and their massive impact on dietary intake. The typical fast food outlet may serve more than 1,500 people every day.
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A supermarket might serve a few thousand customers every day. As we have seen, the design of restaurants and markets and how they present and promote food strongly influence what people eat. We already have a huge infrastructure of “food police,” but they currently focus only on food safety and the prevention of infectious diseases like
E. coli
and salmonella. These “food police” inspect factories, supermarkets, and restaurants and make sure that the food served
is prepared and stored hygienically, and that appropriate equipment is available and functioning.