I have been discussing “big questions” we need to ask as we envision restoring healthcare organizations once the pandemic comes under control, because my personal experience has been that we could not maintain the psychic tension needed to think about those big questions. As a result we got nothing done. Earlier in my career I also got interested in trying a multimodal approach to helping morbidly obese people achieve weight loss. I learned a lot about the problem, including that as a society we have made it nigh unto impossible for people to lose weight and keep it off.
I once told a consultant that ours is probably the first generation in history where almost no one has to worry about getting through a long winter. Not so long ago, people had to work the better part of the day to acquire the calories needed to get everyone in the family fed, and often this involved doing physically taxing work. Now an hour’s work at minimum wage will buy a day’s worth of calories at any fast food outlet. The traditional “standard” diet was heavy in fats and carbohydrates, to provide the calories, and low in protein, to save money.
Then we had the cultural memes. The one I grew up with was “the starving masses of Africa would love to have the food you are throwing away.” (The consultant said in her household, the masses were in Asia.) This aphorism was coupled with “cleaning your plate,” and “waste not, want not,” saving left-overs until tomorrow. We have made some progress in my household—we can save the leftovers until they become moldy, and then throw them away. Of course, we are contributing to the plastic waste stream and we have the disposable income to afford this approach.
Downs and Volpp raise similar issues as they consider barriers to standard medical advice to lose weight, exercise more, etc.
“Technology—and the way it has shaped our behavior—has created a society for which humans are maladapted. Our bodies are not designed for a world where cheap, calorie-dense, processed foods are abundant and healthy foods are more expensive and harder to find; for a car-based transportation infrastructure that leaves little opportunity for active transport modes like walking and biking; or for today’s golden age of entertainment, with infinite content and binge-watching as the new normal, giving us more and more reasons to stay indoors, rooted to our couches.”
Their short paragraph summarizes the social structures that make our standard medical advice difficult, if not impossible, for patients to follow, much less achieve success. Downs and Volpp propose several possible new ways to help patients be successful, but none, in my view, are likely to overcome the enormous social barriers. After all, every one of the conditions enumerated represented hard work by many people, and were designed to overcome the age-old problems of starvation, exhausting physical labor, and/or boredom, which is why we have all adjusted to them so quickly. Nor is this just a problem in the United States—the phenomena, with their attendant impacts on health—has been observed in many countries just now attaining economic stability.
Since these conditions are now considered “normal,” making decisions to make changes so we can improve our health is going to require making new decisions at the societal level. We can stay out of the fast food joint, we can stop being members of the clean plate club, and we can get off the couch, particularly if we change the cultural memes. But this is a problem for advertisers and politicians, not doctors, nurses, and healthcare administrators. Our skill set does not include influencing people in large numbers, and that, in my view, is what is needed.
Some years ago, a large multinational company with a local operation got interested in defining what constituted “good medical care” and how they could identify “good providers” for their employees. A team came and met with us to seek our thoughts as medical professionals. They began the meeting by discussing one of their major products, which had not existed only a few years before the meeting. They talked about how their market research suggesting a hole in their current offerings and how they had then developed the product and created advertising to drive demand for a product people did not even know they needed. The presentation was informative, but I was provoked to observe we needed them to develop campaigns to not “biggie size” our meals, since we did not know how to do that.
I had a patient who was struggling with obesity and related health issues. He was a very successful entrepreneur, so money was not a limiting factor, but he had problems in his home life and now ate dinner at an “all you can eat” restaurant in his neighborhood. I went through my standard 30 minute discussion about all the traps out there to sabotage weight loss, but did not have much hope for change. To my surprise, at his next visit he had managed to lose more than 30 pounds. I asked him how he had done it. He responded, “Well, I thought about our discussion and I decided I was going to spend $6.95 plus tip to get full, not to see how much I could eat for that amount of money.” That was a contrast to the university professor with similar issues who told me: “Doc, did you know Kroger puts the food from their food bar on clearance at 4:30? You can get some great discounts.” How many of us buy the meal deal rather than order only what we really need because the fries are practically free?
So, maybe this is another one of those big questions we should be asking ourselves. What needs to change to improve health that is NOT part of our skill set? How do we approach those who might have relevant skill sets and get them interested in helping us improve population health? Certainly, the pandemic experience has shown that the medical profession and individual expert physicians alone can’t get out in front of the public and talk about “the science” of epidemics and their control with any success if they don’t have backing from the political establishment and other players in our society. If we have learned anything from the pandemic of lasting value, it might be that medicine and its issues are not central to daily thinking of most of our citizens, and they may also worship other idols besides science. In the language of international relations, we are a small island that attracts attention from a lot of other nations, many of which don’t have our best interests in mind, so we need allies who have armies more adapted to the address challenges.
7 February 2021
 Downs S, Volpp KG. Improving Health Outcomes in the US: Let’s Stop Relying on People Swimming Upstream. NEJM Catalyst 18 December 2020. DOI: 10.1056/CAT.20.0559. Downloaded 31 December 2020.
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