When history is being made, it’s not always obvious what the ramifications of an event will be down the road. In fact, predictions of dire future consequences are nearly always wrong, or at least place “blame” on the wrong source. What does this mean? What WILL this mean? These sort of hand wringing questions lead us to all sorts of soap boxing about why event X is going to be the downfall of western civilization, or its salvation. We usually feel silly after the benefit of hindsight, wondering what were we thinking? I refer you to the case of all clothes worn in the 1980s.
So I do not want to be completely reactionary about the news of the AMA vote to declare obesity a disease. We’re all trying to deconstruct what it means, what it will lead to, I’ve been reading reactions, participating in discussions.
Let’s get started with a comic take from one of my favorites, the late great Mitch Hedberg. This won’t embed properly, but it will pop in a new window.
I’ve always loved that bit, but it’s a hard thing to hear now that Mitch is gone, from substance abuse. Sometimes our most talented are our most tortured.
But yes, the word DISEASE is problematic. I am sure there is a value in parsing the term according to the AMA standards. Most of the online discussion is centered on just that: What does disease mean? It’s telling that we’re still not sure. I avoided the 12-step program for a long time because of disease language. And some of the possible implications of using that word are a major turnoff for people, and will invoke a lot of negative response. I completely understand why.
I’m here to offer one more voice in the conversation, and the bottom line for me is this:
A disease is a state of being, which can happen many ways: it’s what you do to treat it that matters.
To simplify the conversation, if that is possible, the concerns I am hearing, and to a large degree, I share them, center on the idea of a disease as something that happens to you, outside your own control. Looking at obesity in this way, it removes personal responsibility, and in fact renders people powerless. Using the classification disease, it is tempting to throw up ones hands and surrender. Diseases are things that happen to you. They are outside of us, and invade us. We expect modern medicine to cure diseases with drugs and surgery. I’m a huge fan of modern medicine curing acute diseases: polio, cancer, AIDS. But chronic diseases that can be prevented, reversed, or treated by non-medical intervention, these are rarely discussed in terms of what WE CAN DO. It’s this growing problem in American society that we react to when we roll our eyes together, and say “oh come on, it’s a disease now? Great, now no one’s responsible for anything.”
I understand that reaction. I share it to a degree. But I also listen to a lot of the debate as a fat guy watching thin people talk about me. When I’ve been in the rooms of 12-step, no one sat there and called their condition a disease and declared the situation hopeless. The language of helplessness is there, but with an appeal to a higher power, and that doesn’t mean Glaxo-Smith-Kline or Merck. When I hear 12 steppers use the word disease it is in reference to it being cunning, baffling and powerful. It is never a “oh this happened to me, nothing I can do now!”
This blog often deal with other questions we will not deal with today, important as they are. Questions of why and how a person becomes obese, how the environmental factors help or hurt, how two people following the same advice and lifestyle will yield different results, how the metabolically broken may have a stricter path to getting fixed, how the diet industrial complex is designed for you to fail over and over and over…….. those are all worthy of consideration. But they do not get at the philosophical point:
OBESITY IS NOT NORMAL
Perhaps the semantic hurdle of this word will make more sense if we think about disease as dis-ease. Illness. A condition opposite health. Then, the question is about what is the status of reality right now. Then we’re not getting into value judgments that sidetrack us into blame. We’re dealing with the situation as it is. If your airplane goes down and you survive on a mysterious island, the question of why the plane crashed is interesting, but not helpful right now. The question is how do I get off the island? I want to be a person who focuses on now what? instead of wallowing in why did this happen?
The debate over disease misses the deeper point: the AMA is strongly saying that being obese is not the way it should be. Obesity is bad. Obesity is not benign. It is harmful and something to be avoided or changed. This, by itself, cannot be understated. This is what I want to focus on.
What’s in a name?
The Greeks defined happiness differently than the way we use the word today. In our world of constant distraction, where we hide sick and old people away so we’re not reminded of our own mortality, happiness is defined in really shallow, entertainment based, hedonistic terms. Ask a modern American to define happiness, and you’re likely to get an answer that is lacking in depth, focuses on material possessions, and has a sad poverty of the human spirit. But ask an ancient Greek about happiness, and you see a definition that has to do with everything being in its right place. Much like the true definition of humility, happiness is about things being the way they’re supposed to be. Now of course, politics, religion, philosophy will all serve as tools to argue exactly what supposed to be looks like. But our modern reductionist, tech-worshiping, CGI-influenced image-obsessed world has definitely gotten off the path of any traditional wisdom. Example: you’re SUPPOSED to cry at a funeral. It’s sad. Even if you believe in something beyond, the loss of a loved one is tragedy. Sorrow is called for. A Greek version of happiness says that loss without sorrow or grief is out of whack, regardless of how happy one may appear to be. For an ancient Hebrew worldview, we have the famous Ecclesiastes passage “to everything there is a season.”
Now that I’ve waxed prosaic on the Platonic ideal of happiness for an unhappily long time, I hope the point is being conveyed: disease as a classification can be helpful IF, and ONLY IF, we use that term to say that obesity is not the way it should be. To borrow the title of a Joel Salatin book, Folks, This Ain’t Normal.
So that’s my best take on the controversy of the use of the word disease. I want to be hopeful that we can use it this way. However, we credit H.L. Mencken with an unfortunate truism: no one ever went broke underestimating the intelligence of the American public. For every Mad Men or Breaking Bad, there’s oodles of Maury Povich and Jersey Shore. So not only am I skeptical of the introspection I hope for when pondering disease, illness, balance, health, I am also always skeptical of associations of medical professionals. In a time of changing expectations of healthcare, of what coverage looks like, of how much intervention through the wonders of modern chemistry are expected as the new normal, is there a less-than-altruistic motive behind this new push to apply disease terminology?
And in that regard, I am afraid to be optimistic. I start to get all conspiracy-theory friendly when I ask what are the economic implications?
And though I just said we can’t predict all future trajectories of new ideas, I feel safe in saying that there is going to be some sort of major fight over coverage, costs, and treatments with this new language. It doesn’t all have to be bad news of course. Maybe a return to doctors being the preventative helpers in our lives is at hand. From the LA Times article on the news this week:
Tuesday’s vote is certain to step up pressure on health insurance companies to reimburse physicians for the time-consuming task of discussing obesity’s health risks with patients whose body mass index exceeds 30. It should also encourage doctors to direct these patients to weight-loss programs and to monitor their often-fitful progress.
I can live with this so far. The truth of the matter is, no one makes money keeping you well. They make money from billable office visits. I live next to the local family practice. I’ve written many times about the huge flow of drug reps I see, but I also see the same cars with the same patients coming literally every week. It’s a small town, I know people. I don’t see their files, but by the numbers of the main ailments in the US and in our area, I know many of these are preventable lifestyle conditions. I was headed there too, and I struggle still. But I refuse to just become a passive pill popper and wait for the doctor to give me another drug. McDonald’s revealed years ago that their business model relies primarily on the heavy user who frequents the place, well, frequently. It appears the healthcare industry is trending in a similar way.
Again, I am not some MD-bashing armchair wannabe expert trying to paint the profession with some nefarious broad brush. I spend a good bit of my time around doctors in hospitals. I know some personally. They are healers. They are called to it. But they are up against a tide of expectations too. I try to be sympathetic. But every so often, I hear a perspective that really challenges the way I see the system and how its constructed.
Dyson Vacuum Cleaners and the American Diabetes Association
I was listening to one of Jimmy Moore’s classic podcasts that he re-ran while on hiatus to write his upcoming book Cholesterol Clarity. I highly recommend this for your listening. It was with Dr. Richard Bernstein, a diabetes specialist who advocates low carbohydrate diets. He recounts his uphill battle against the establishment that is the AMA and the ADA. It is a compelling interview. He is basically the inventor of the home blood glucose monitor. His innovation was not well-received at all. He was told flat out that if a person can do their own testing, then they are putting their doctor out of business if they don’t have to come in for the test. He goes further, with some damning analysis from others within the ADA that admit the organization itself is really a trade group for physicians, as opposed to having a primary mission to help diabetics. Again, tinfoil hat on securely now, but how else do you explain the ADA advocating the high carbohydrate diet for diabetics that they do, if not to promote a status quo of pharmaceutical intervention?
Look, it’s not a stretch to see this as a real possibility, even within the noble profession of healthcare. As long as we’re in a profit-driven system, it will have benefits and downfalls. Innovation is a major benefit and I do not want to sound like a communist anarchist anti-capitalist. But look no further than the story of the Dyson vacuum cleaner. I love that guy.
Dyson invented a revolutionary bagless system in the 1980s and tried to get major vacuum makers to buy in. No one was interested. He got the same message again and again: why would we want to cut off our sales? After they buy the hardware, we get them buying our bags over and over. Hey Vinnie, sound familiar? Like children’s network execs saying their bills were paid by the sugar/cereal industries you wanted to take on? Of course you all remember the terribly low quality bagless vacuums that came once all the companies tried to rip off the idea and failed miserably. Eventually he secured capital to found his own company, and I am such a proud owner of my purple Animal upright, I could sell these things.
The same thing eventually happens when status quo tries to keep innovators from reaching people with new concepts. Now home glucose testing is common, but as long as diabetics follow the ADA dietary guidelines with inexplicably recommend whole wheat bread*, yet demonize saturated fat, everyone STAYS DIABETIC, stays on medications, and visits the doctor constantly. *Whole wheat bread has been shown to raise blood glucose more quickly, and higher, than a glass of soda.
So forgive me for sounding paranoid, but yes, yes, yes. I have a raised eyebrow when it comes to the AMA and their financial incentive in classifying things as diseases. I’m not predicting the sky to fall, but let’s pay close attention to how this language impacts healthcare, especially in funding. If this means disease-prevention will become more prevalent, great! If this means more and more billing to treat with drugs and surgery as the new normal: well, we get what we ask for, don’t we?
What difference will this make to my life?
I know my obesity is not the way things should be. Whether or not someone wants to call it a disease, and what they think that means, is of little consequence to my way of dealing with life. I will continue to question the status quo, examine my own habits, motivations and dysfunctions, and seek truth in natural/traditional/ancient wisdom. I will not seek a fix for a disease of civilization from the same technologies that help to further it.
In other words, I’m not defining my life by AMA terms, ADA terms, or drug company terms. I’m looking to tomorrow, as always.