You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010


Monday, August 2, 2010

One Step for a Giant Man

It was 1961 when President Kennedy inspired the nation with his call to land an astronaut on the moon, before the end of that decade. He did not live to see that accomplished, but it was a proud moment for those who did see it. The decade presented huge challenges to Presidential leadership, including Vietnam, Civil Rights battles, the Cold War, and national dismay with high profile assassinations. In spite of all the diversions which could have derailed the journey to the moon, NASA continued the research and planning to finally fulfill the President’s vision.

In 1971, President Nixon declared both the War on Drugs and the War on Cancer. This was perhaps emblematic of his temperament. The War on Drugs has been a failure, not because of its intention but because of the way it has been waged. Nevertheless, state and federal governments have continued to allocate billions of dollars per year to the task of diminishing the destructiveness of drug abuse in our society, and in that sense, Nixon’s leadership has had long term impact. The War on Cancer started with an allocation of $100 million to find a cure for cancer. In recent years the National Cancer Institute has been spending just shy of $5 billion on cancer research, 50 times Nixon’s allocation. While we have made much progress with some types of cancer, anything which can be called a cure is still nowhere in sight. The priority we have placed on space exploration, drug addiction, and the causes and treatments for cancer has greatly expanded our knowledge and capability. In that way, each of these “Wars” or priorities has reaped benefits.

Recently it was announced in the media that there is a gradual shifting of health dollars away from tobacco toward obesity. The nation’s anti-tobacco campaign started in the 1950s with population studies on smoking and cancer. Another early sentinel moment in the anti-tobacco campaign was the release in 1964 of the first Surgeon General’s report on smoking and health. Since those years, tobacco control efforts have been a priority of the public health community; strategies to reduce smoking have become more and more stringent and comprehensive. Our understanding of why people start and how to help them quit is not complete, but is infinitely more complete than in the early days.

As a result, we have gone from a time when over half of adult men smoked to now about 23% of men and 18% of women. Among all the ways we try to discourage smoking, one considered very effective is increasing price. Twenty years ago Big Tobacco Companies and Big Tobacco Farming and Big Tobacco Politicians were powerful enough that raising the price of tobacco taxes was very difficult to do. That genie is now out of the bottle, and all states are increasing their excise taxes, mostly to balance their budgets, but also to discourage smoking. This is going to continue for many reasons. Though some wish governments were more influenced by the health harm of tobacco, motives don’t really matter as long as policies and programs are in place. It is hard to imagine our society going back to smoking as it was done in the 1940s and 50s, regardless of public health funding.

Some in the public health community are raising alarm bells because shifting funding away from tobacco might signal that a loss of priority for what is still America’s number one most preventable cause of death. There is the concern that without continuing relentless pressure against tobacco marketers and those who benefit from tobacco use, our gains in the anti-tobacco campaign will be whittled away over time. To me that sounds alarmist, and for some, self-serving. There is a huge infrastructure in state and federal governments as well as community-based agencies supported by tobacco funding; these entities have a vested interest in seeing the funding continue. That is not to defame the good work that they have done, but simply to recognize that turning off the tobacco funding faucet threatens job and agency security.

What is the justification for shifting funding towards obesity? First, it is good stewardship to recognize that choices sometimes must be made. We can’t do it all. While all the trends with tobacco are going in the right direction, they are all going in the wrong direction with overweight and obesity. A fundamental social change has occurred with tobacco. Forty years ago you never heard the question “Do you mind if I smoke?” Now, smoking is considered socially unacceptable in many parts of our society. If you smoke it is not something you want people to know. This change was brought about by the priority placed on tobacco control by the public health enterprise in government and the public sector. Now we recognize a fundamental change in patterns of overweight. In the last 20 years the weight distribution has dramatically changed. Something has changed, and we are still trying to get our hands and heads around the causes and how best to respond.

I’m hoping that no leader will draft the “War on Obesity” label because it is overused and a dubious metaphor. Nevertheless, high profile funding changes by the Robert Wood Johnson Foundation and the U.S. Centers for Disease Control are symbolic of leadership determining to set a new priority for the very real threat of overweight and obesity in children and adults. Perhaps in ten years we will be inspired, not by one person walking on the moon, but by all of us walking in the moon’s light.

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