Why eating isn't like smoking
I forgot to link to my latest Food policy column, but it centers around a farmer's market stroll with OMB health-care policy adviser Ezekiel Emanuel. The government is fairly sure-footed when it comes to health-care policy. But what about when it comes to health?
The government really doesn't know what its role should be when it comes to how Americans eat. It knows that it can't afford Medicare and Medicaid if the rise in such diet-related conditions as diabetes, heart disease and cancer doesn't level off. But what does that imply? Should Peter Orszag publish a cookbook? Should Emanuel have a cooking show? Should fruits and vegetables be heavily subsidized? Soda taxed? The head of Hardee's executed?
Our political system is a lot more comfortable talking about health care than about health. We'll pay enormous amounts of money to treat diabetics, but we don't do much to change people's diets to prevent diabetes. That's a strange use of resources: Focusing on health-care coverage without doing more to address the factors, such as diet, that determine our health is a bit like buying fire insurance while ignoring the fact that you have a gas stove and a large fireplace in a wood cabin. A dry wood cabin.
It's better to prevent fires than rely on fire insurance, as homeowners know. But preventing fires, it turns out, is really hard. "My own view," says Emanuel, "is we know there are large parts of health that are primarily best approached as a public-health issue and not as a doctor-patient issue. Nutrition, wellness, exercise and smoking, for instance. But lifestyle change is hard to accomplish. What smoking showed is it's not a single thing. It changed from being socially acceptable and doctors would recommend it in the '50s to being scorned and barred indoors."
The smoking case is an interesting one. Emanuel brings it up repeatedly as one of the few examples where public-health advocates managed to change the culture around a previously unexamined act, which is exactly what they're going to have to do with diet. "On smoking, there are a combination of things that had to happen," he says. "We had to make smoking socially unacceptable. We took it outside the building. We raised taxes on it. It became linked to cancer." But as he admits, "you can't take eating outside the building." Nor can you demonize it entirely. Certain products can be attacked, but in a world of organic Oreos and Splenda with added fiber, it won't just be an uphill climb. It'll be a climb with constantly changing footholds.
Talking to folks who worry about food policy is a profoundly depressing experience. Even the optimists -- and Emanuel probably counts as one -- are looking back at an example that seems, in retrospect, immeasurably easier.
After all, the big insight with cigarettes was that they were physiologically addictive in ways that led directly to excess (it took more nicotine to satisfy the craving) and so we had to keep people from ever starting to smoke. Food is also addictive, and people have trouble with moderation, but the answer can't be that people don't eat. They have to eat. Every day. The problem is that once people start to eat, they find it hard to stop, an observation that's now been buttressed by plenty of experimental data. Imagine, however, how hard it would be to keep people from smoking very much if everyone needed five cigarettes a day.
Or take the dangers of secondhand smoke, which provided the crucial evidence of external harm that led to states banning indoor smoking. You're not going to get that with food. Or take the banning of cigarettes for people under 18 years old. Who wants to be the first to limit Wonder Bread to adults?
Which is all to say that the single workable playbook is almost entirely useless here. But in the absence of some genuine breakthrough, we're going to be a pretty sick society. And with Medicaid and Medicare threatening to bankrupt the country, and private insurance costs chewing through our wages and sitting heavily atop our employers, that's going to be a serious problem.
Photo credit: By Wilfredo Lee
November 5, 2009; 5:32 PM ET
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