Imagine a world- perhaps much like this one- where, in the beginning, there was no air pollution- and then there was some.
Imagine that most people were not highly sensitive to that first, little bit of air pollution, and thus- most people did not cough or gag in response to it.
There were, however, in our imaginings, some people who were highly sensitive and who did, therefore, cough or gag. They were viewed by all the others as weak and self-indulgent, as complainers and sympathy seekers. They were, in other words, ostracized and their characters were impugned – and all because particulate matter in the air emitted by the first offshoots of an industrial revolution made them cough.
As time went on, the impact of that industrial revolution advanced, so that wherever there had been one smokestack, there were now many. The concentration of particulate matter in the air rose, and with it- so rose the prevalence of coughing and gagging.
Somehow, though- despite the evidence hiding in plain sight that an environmental exposure for which individuals bore no personal responsibility was making ever more of them vulnerable to its adverse influences- the attitudes about character and victim blaming, born of the era when vulnerability was the rare exception, persisted into the era where it was fast becoming the norm. Such is the power, it seems, of cultural inertia: an attitude may be opposed by evidence on daily display, yet still retained because it was what everyone believed yesterday.
With the passage of yet more time, and ever more smokestacks, the levels of airborne particulates reversed the original formula entirely: now, only those individuals with rare resistance to the ill effects made it through a day without coughing or gagging. These were, generally, people of means- who lived on the hills where altitude, breezes, and such flora as yet survived provided the best possible defense against the declining air quality. Even many of these coughed and gagged, but they coughed and gagged less. And those who did not- yet- cough and gag were found all but exclusively among their number.
Let us say, for argument’s sake, that by now- more than 70% of everyone was coughing and gagging every day. Even so, the disparagements and eye-rolling and victim-blaming persisted, for such is the power of cultural inertia. We believe, with remarkable tenacity, whatever our culture inculcates into us as “truth.” Evidence that belies it hides readily in plain sight.
But while the reasons for the coughing and gagging remained mired in biases, the very scope of the problem now attracted a new kind of attention. There was, at long last, the recognition that something really ought to be done about all this.
And accordingly, something is. The powers that be, prominent among them the proprietors of every neighborhood’s smokestacks, lobby to give the problem a name, and the House of Medicine obliges with adult-onset reactive respiratory particulosis (ARRP). Thus is born a disease.
At first ensues a cottage industry in questionable lotions and potions to alleviate the inconveniences of coughing and gagging among the afflicted who, though now respectably diagnosed with a bona fide medical condition, are still all too often objects of disdain (even by others succumbing to the same condition). One might think that cognitive dissonance would obviate such hurling of stones in glass houses - but one would be wrong. Or so we imagine.
Eventually, lotions and potions yield terrain to the weightier efforts of titans in the pharmacology and technology domains. Prescription drugs are used widely for the coughing and gagging, with some measurable relief resulting, along with some nearly commensurate, if unintended, harm.
All the while, naturally, the smokestacks proliferate, and the levels of the offending particulates in the air relentlessly rise. Why wouldn’t they? The problem has been declared a “disease,” and thus the fault resides with the human body- not the machinations of the body politic. The body politic may proceed, and profit, with impunity- no matter the sputum and sputtering, the mucus and malaise. Remedies are directed not to the true origins of our discomforts, but to where our culture persuasively assigns blame.
Eventually- and to great fanfare- a breakthrough is announced. A particular advance has been achieved in gas mask technology, allowing for a reliable defense against more than 99% of the prevailing airborne particulates. The military-industrial establishment predictably lines up behind the obvious proposition: gas masks for all!
And so, in our imaginings, it goes.
Of course, the levels of particulates in the air are now high enough to induce symptoms among even the very young and resilient. Accordingly, what was once a disease starting generally at around midlife- ARRP – becomes a pediatric scourge as well. Children with less severe cases of the malady routinely bully and belittle those with more severe. The House of Medicine graciously renames the condition – human reactive respiratory particulosis (HRRP) – lest its diffusion among our children feel too jarring. Debate ensues over the age at which gas mask use is first appropriate: 12?; 10? Perhaps 7?
Few question or challenge the “gas masks for all” campaign, as it is just as the sociocultural status quo intones it ought to be. Some few- largely regarded as radicals, heretics, nannies, ninnies, if not lunatics- point out that the problem resides with the smokestacks. They presume to note that leaving aside the specific pros and cons of gas masks for all, the ills of ever-rising particulates in the air are not confined to the human respiratory tract. In the tedious, annoying, presumptuous way of those who simply can’t accept that how things are is how they ought to be, this cabal cites contamination of water; harms to the respiratory tracts of other creatures; the sickening of trees; the degradation of soil; the acidification of seas. They go so far as to assert that gas masks do nothing whatsoever about any of these diverse, other adversities.
They are right about all that, of course. But it’s nothing the flexing of some marketing muscle cannot readily crush and overcome. And so, in our wild imaginings, it goes.
I invite you, now, to substitute the proliferation of willfully addictive, ultraprocessed foods for all that particulate matter; obesity and type 2 diabetes for ARRP; the renaming of “adult onset diabetes” as “type 2” for HRRP; GLP-1 agonists and bariatric surgery for gas masks; obesity bias for the abuses of those coughing in response to polluted air; the labeling of obesity as a disease; the inattention to root causes; the victim blaming; the emphasis on surgery and drugs that divert focus and resources from the root causes; the myriad other harmful effects of manufacturing a supply of ultraprocessed junk where food ought to be. You may give your imagination a rest; truth is, indeed, stranger, and more damning, than fiction.
Just as gas masks should be available as a last resort to those contending with unbreathable air despite all best efforts to keep air breathable, so, too, should drugs and surgery be accessible as last resorts in the treatment of obesity that occurs despite best efforts to keep food nourishing and physical activity practicable. But drugs and surgery should not bemuse us into mistaking effects for causes, obnubilate us into desperately seeking remedies while floridly propagating the malady.
And so, in our reality, it goes. Obesity, diabetes, and the attendant plagues of modern epidemiology are propagated, for profit, by entire industries; even as other entire industries profit by proliferating treatments. The problem, at its origins, is systematically ignored, left to worsen with the whims of corporate boards and shareholders, with stock prices and quarterly revenue.
The equilibrium is perfect. Both cause, and effect are lucrative. Culture tells us all is as it should be.
What could possibly go worng?
Note: I was originally goaded to develop these reflections, and this analogy, by my friend, Mark Bittman, who blended them into two thoughtful and provocative columns. With his knowledge and kind indulgence, I am borrowing them back for this column of my own.
P.S. – this is, alas, all more or less true regarding air pollution as well, a major public, and planetary, health problem in its own right. For today’s purpose an analogy, it fully deserves to be the primary topic. I leave that to another day, another column, and other authors more expertly qualified on the matter than I.
Dr. David L. Katz is a board-certified specialist in Preventive Medicine/Public Health, past president of the American College of Lifestyle Medicine, founder of Diet ID, Inc, and Chief Medical Officer for Tangelo, a food-as-medicine platform. He cared for patients for roughly 30 years, and made selective use of prescription “weight loss” drugs during that time. He has authored multiple editions of leading textbooks on both nutrition and epidemiology, and is the co-author, with Mark Bittman, of How to Eat.
David L. Katz, MD, MPH, FACPM, FACP, FACLM, is the Founding Director (1998) of Yale University’s Yale-Griffin Prevention Research Center, and former President of the American College of Lifestyle Medicine. He has published roughly 200 scientific articles and textbook chapters, and 15 books to date, including multiple editions of leading textbooks in both preventive medicine, and nutrition. He has made important contributions in the areas of lifestyle interventions for health promotion; nutrient profiling; behavior modification; holistic care; and evidence-based medicine. David earned his BA degree from Dartmouth College (1984); his MD from the Albert Einstein College of Medicine (1988); and his MPH from the Yale University School of Public Health (1993). He completed sequential residency training in Internal Medicine, and Preventive Medicine/Public Health. He is a two-time diplomate of the American Board of Internal Medicine, and a board-certified specialist in Preventive Medicine/Public Health. He has received two Honorary Doctorates.