This is Chapter 12 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.
You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.
And here is the up-to-date archive for all the chapters that have been posted so far.
Update – September 1, 2012
Open Wide and Say Moo! is now revised and published!
Now available in the audiobook version!
In the previous chapter we considered the role that preventive medical services will play under Obamacare, which is to say, as little a role as possible. Indeed, preventive medical services, since they will always cost the system far more money than they can ever save, will be de-emphasized at every opportunity, and outlawed when necessary.
So when our leaders promised that Obamacare would be all about “prevention, prevention, and prevention,” were they simply lying to us? No. In fact, it appears, they remain very serious about preventing illness. It’s just that when they say the word “prevention,” they’re not talking about preventive medical services like screening tests or prophylactic medications. Instead, they’re talking about inducing all of us within the herd to adopt healthy lifestyle choices, such as eating wisely, maintaining a healthy weight, and getting plenty of exercise.
These lifestyle choices would of course undoubtedly be good for us (assuming we could agree on what we mean by eating “wisely,” or what a “healthy” weight is, or how much exercise is “plenty”). But I don’t think very many Americans realize yet just how serious our Progressive leaders are about correcting our suboptimal living habits and putting us on the right path to good health, or to what lengths they would be willing to go in order to get us there. This is in fact a very serious matter to them, because the way we each live our lives goes to the very core of the Progressive program.
On the broad scale, it is not possible to develop a perfect society if the citizens who live within that society follow their own personal whims, and engage in self-indulgence, overeating, sedentary living, or any of the other myriad of behaviors by which we reveal ourselves not to be working relentlessly for the benefit of the whole.
Focusing more narrowly, a Progressive healthcare system simply cannot function efficiently if the citizens whom it serves do not take every precaution to maintain their own good health. Those who, through their own lack of self-discipline, allow themselves to develop an avoidable illness are affecting more than just themselves. They are robbing their fellow citizens of resources that might otherwise have been theirs, and possibly more importantly, their infirmities will detract materially from the aura, projected by any ideal society, of a happy, healthy, robust citizenry, all working harmoniously for the greater good.
Therefore, under any system like Obamacare, where providing healthcare to everyone is a collective responsibility, maintaining your own wellness is not merely something you ought to do for your own good. It is your sacred duty to the collective.
And if your chosen actions (or inactions) cause you to become unwell, and if your unwellness causes you to consume healthcare resources which otherwise might have been available to more deserving individuals who (unlike yourself) became ill through no fault of their own, and if such faultless individuals subsequently suffered or died as a consequence of your failure to honor your duty to remain healthy, well then, your failure to perform your duty would make you no different from any other common criminal whose selfish actions produce harm to their innocent victims. Maintaining your wellness is not a nice-to-have; it is your non-negotiable obligation.
And the Central Authority, consequently, has an equally sacred obligation to hold you to your duty.
You have been told, by the caring people who will be running our new healthcare system, that your wellness is very important to them. And so it is. This is why you will, by law, be “entitled” to annual, detailed “wellness checks,” provided by the dedicated team of healthcare workers which will be assigned to your care, and which will assess (and record) your efforts to maintain your own wellness, and then will give you all the instruction you could possibly need to alter whatever suboptimal behaviors you may be currently displaying. The results of these annual wellness checks will be entered into a federally-approved universal electronic medical record, so that any healthcare provider, anywhere, at any time (or any agent of the Central Authority who finds access to your records convenient to his or her own special purposes) will have a complete record of the trajectory of your state of health over the years – and of the degree of your compliance with the instructions you have received for maintaining your wellness.
Of course, if you elect to forgo the annual wellness checks to which you are entitled, that information (i.e. that you cared so little for your wellness that you couldn’t be bothered to do anything about it) will also be maintained in the universal electronic records.
Then, when you become ill 10 or 20 years from now, your health records (along with other pertinent electronic records of your past behaviors, such as your annual purchases of ice cream and salt, the volume of sedentary entertainments you download from Netflix or the App Store, and your relative propensities for purchasing running shoes and Barcaloungers) can be consulted to decide to what extent your illness can be considered self-induced. For, when resources are scarce, the only moral thing to do is to distribute them according to who is the most deserving.
I understand this may sound just a bit paranoid. So let us reflect for a while on a particular pattern of behavior already being displayed by our Progressive leaders, regarding a supposedly self-induced medical condition.
In his book “The Amateur: Barack Obama in the White House,” Ed Klein relates Michelle Obama’s reaction when Oprah Winfrey asked the First Lady to appear on her TV show to discuss the problem of childhood obesity. Ms. Obama flatly refused the offer, allegedly saying, “Oprah, with her yo-yo dieting and huge girth is a terrible role model. Kids will look at Oprah, who’s rich and famous and huge, and figure it’s OK to be fat.”Ms. Winfrey herself was said to be quite disturbed by this rejection, allegedly complaining, “Michelle hates fat people and doesn’t want me waddling around the White House.”
An attitude of disdain (if not outright hatred) has been studiously adopted by many Progressives toward people who are obese. Even Saint Oprah – who is dearly beloved by women and men of all races and ages, whose good works in America and abroad are admired by all, whose early endorsement of Barack Obama was arguably the event that ignited his winning the White House, and what’s more, who has often and famously striven to lose weight, her mighty and even heroic struggles to do so embodying the tremendous difficulties faced by people above a certain age who endeavor to get their weight down to publicly acceptable levels – is not to be given a pass. Despite everything she has accomplished, Oprah’s weight renders her a negative role model.
This, because being overweight is simply too great a sin to be tolerated.
We are, in fact, witnessing a sustained and concerted campaign to demonize the obese. It is a campaign which is being conducted with a great end in mind.
It is not difficult to demonize the obese. In literature and films the obese have long been portrayed as unreasonably jolly (which itself is a great sin in any serious society), or as slovenly and lazy, or as just plain evil. (Hello, Newman!) Nobody likes to sit next to fat people on airplanes or buses. They block the aisles at the grocery store (their favorite haunts). They reduce miles-per-gallon when they ride in our cars, and if they insist on sitting in the same seat every time, they cause asymmetric tire wear and thereby produce automobile accidents. On humid days, they sweat (and thus stink) more than you and me. And, of course, they are unsightly. So, with rare exceptions nobody complains when the obese are criticized and attacked.
It is remarkable that I can write a paragraph like the one I have just done without any serious qualms or concerns about how most readers might perceive my lack of sensitivity. Unless you, dear reader, are yourself fat, I have no concerns about having offended you, for I have said nothing that is not perfectly acceptable in modern American discourse.
Given the current hypersensitivity we see to anything smacking of criticism of various races, ethnic groups, professions, political movements, sexual orientations, immigration status, victims of certain diseases, and scores of other categories of Americans, the obese present us with a refreshingly safe target upon which to unleash vituperation and innuendos. Insulting obesity is not only acceptable but encouraged. We can say about the obese just about anything we like. It is perfectly fine to insist that it is the obese – those lazy, self-indulgent fat people – who are driving our healthcare spending off a cliff. Prominent and respected figures appear to feel no compunction whatsoever against making the most offensive public statements against the obese, and when they do they generally receive applause rather than condemnation.
Demonizing the obese is now such a prominent theme in American life that it has become difficult to satirize. In 2011, when Governor Christie was still entertaining the possibility of a presidential run, I wrote a blog post urging him not to do so because he is just too damned fat. Fat people, I noted, have characteristics we do not like to see in presidents (sloth, gluttony, lethargy, &c.), and allowing a fatty to aspire to such a high position would create the false impression that obese people are worthy of any consideration whatsoever, and would make people think that the obese ought to have the same individual freedoms as the rest of us. Furthermore, I allowed, a Christie candidacy would amount to a serious setback to the Progressive program (which is to say, controlling individual behaviors for the great benefit of the collective). When I further urged the Governor to stay in New Jersey, except perhaps to occasionally cross the state line just long enough to stock up on Philly cheese-steaks, I believed myself to be engaging in the outlandish extremes customary to a master of irony.
So imagine my surprise when, just after publishing this diatribe, an article by Michael Kinsley appeared on Bloomberg also declaring Christie too fat to be president. The reason? Because “a presidential candidate should be judged on behavior and character, not just on policies.” Fat people, Kinsley elaborated, are a “perfect symbol of our country at the moment, with appetites out of control and discipline near zilch.” In other words, fat people have shown themselves, by their very obesity, to be entirely unworthy characters, and being unworthy, should not aspire to the presidency, or presumably, to any other position of importance. Eugene Robinson of the Washington Post shortly thereafter agreed that Christie’s weight should prevent him from running, noting that the “obesity epidemic” is costing the government a lot of money, and implying that people like Governor Christie are responsible for the massive federal deficit. This being the case, his candidacy would be entirely inappropriate. So there you have it. Actual Progressives were making the very same arguments for Christie to stay out of the race that I made in what I had thought to be a brilliantly satirical blog post.
A chief advantage for choosing obesity as a prime target for public castigation is that obesity is a condition which is immediately visible to all – there’s no need to sew a Star-of-David-like emblem to fat people’s clothing. So unlike, say, closet smokers or pedophiles, it is a simple matter to identify, at a glance and at a distance, those obese individuals whose selfishness and laziness are costing the rest of us our healthcare dollars, and thus, potentially our lives.
Fully government-funded and government-controlled healthcare permits – and even demands – that we declare to the obese that their unsightly physiques are no longer a matter of personal choice, but are now a matter of legitimate public concern. The choices they are making – that is, their gluttony, sloth, &c. – are placing unwanted and unsustainable demands on us purer, svelter, fellow-citizens, not to mention placing us in danger of not receiving the healthcare which we (in contrast) actually deserve. Hating the obese has become nearly a patriotic imperative.
There can be no doubt that obesity is a significant health hazard. When you are grossly obese, virtually every organ system in your body is negatively affected, and your risk of developing diabetes, heart disease, vascular disease, kidney disease, and other expensive illnesses increases markedly. Severe obesity is a severe health hazard.
In our public discourse, however, the hazards of severe obesity are being projected onto people who are merely overweight*. But the hazards of being only modestly overweight are much less clear.
* The Centers for Disease Control defines weight categories, according to body mass index (BMI), as follows: BMI scores of 20 to 24.9 are considered normal, scores of 25 to 29.9 are overweight, scores of 30 to 34.9 are obese, and scores above 35 are extremely obese.
For instance, in 2002 a report in the Journal of the American College of Cardiology examined almost 10,000 consecutive patients who had angioplasty and/or stenting for coronary artery disease, and found that those who were overweight or obese had fewer complications and a lower one-year mortality than those who were thin or of normal weight. Several more recent studies claim to have shown the same thing.
A 2007 report in the Journal of the American Medical Association showed that overweight people who were physically fit had a lower risk of death than normal-weight people who were sedentary. Another 2007 report by the National Bureau of Economic Research noted that while Americans were growing fatter, other changes in health behavior (such as reduced smoking and better management of cholesterol and hypertension) more than offset any increase in health risk posed by the population’s increase in obesity.
In 2009, a meta-analysis in the Journal of the American College of Cardiology concluded that while obesity itself increases the risk of heart disease, obese people who develop that heart disease have significantly better survival than thin or normal-weight people who develop the same kind of heart disease. Some cardiologists have already termed this growing line of evidence, i.e., the general observation that at least in some situations overweight cardiac patients fare better than thin ones, as “The Obesity Paradox.” Such phenomena as an Obesity Paradox, however, are too inconvenient to be brought up in public discussions on the hazards of obesity.
In addition, while there is no question that Americans are becoming fatter, the magnitude of the increase in our obesity over the past two decades has been at least somewhat exaggerated by a change in the definition of obesity. When the CDC changed that definition in 1997, as many as 30 million Americans who went to bed at a normal weight woke up the next morning to find themselves overweight if not obese, and all without gaining a pound.
Also entirely ignored in the public discourse is the accumulating evidence that one’s weight-related medical risk (like blood-pressure-related risk, and salt-intake-related risk) appears to be “U” shaped. That is, one’s risk goes up when one’s weight becomes either too high, or too low. Several epidemiological studies have suggested that, while overall mortality rates indeed begin to climb when the BMI exceeds 25, they also begin to climb as the BMI drops below 22.5. If this is true, then a) the optimal BMI lives in a very narrow range (22.5 to 24.9) where relatively few of us are permitted by nature and our genes to dwell, and b) by rights, we should be castigating the underweight with the same vituperations we are encouraged to heap upon the fat.
Finally, the idea that the obese are using more than their share of healthcare resources may be incorrect. An article published in 2008 in the Public Library of Science Medicine Journal compared the lifetime cost of healthcare (beginning at age 20) for obese individuals and for smokers to the lifetime cost for non-smokers who maintained a healthy weight. Naturally, the study concludes that the healthy individuals can expect to live longer than the obese and the smokers (84 years vs. 80 and 77 years, respectively). However, the healthy young people will consume $400,000 in lifetime healthcare costs, vs. only $365,000 for fat people and $321,000 for smokers. The cost savings this study discovers with the obese and the smokers are provided courtesy of their premature deaths. Therefore, normal-weight non-smokers, over their lifetimes, appear to cause a bigger fiscal drain than the obese and the smokers – and eliminating obesity and smoking would create an even bigger strain on our healthcare system.
According to the Wall Street Journal (August 23, 2006), the CDC has instructed its researchers not to comment on such contradictory research on obesity, in order to avoid creating “public confusion.”
At a time when we are studiously ignoring research which sheds at least some doubt on the significance of being modestly overweight, other “research” on obesity, research which by any objective standards seems staggeringly stupid, is being published with great fanfare. I will give two notable examples to demonstrate the point.
In 2009, Professors Edwards and Roberts penned an article demonstrating that fat people are largely responsible for global warming. Their article was published by the prestigious Oxford Press in the International Journal of Epidemiology. This paper, which indicts a whole class of individuals with the supreme crime of global warming – a crime which will prove to be of such stupendous proportions, apparently, that even the atrocities perpetrated by Hitler and Stalin will seem mere trifles in comparison – reaches its conclusions without ever offering even one tiny glimmer of actual data or evidence.
Rather, the authors rely (in the style of their apparent forebears in the tradition of Scholasticism) on the already-approved body of scientific work, choosing from that body an array of assumptions based on bits of sanctified data from physiology here (e.g., Basal Metabolic Rate = 11.5 X body weight in KG + 873kcal), and behavioral science there (e.g., that the average daily activities of humans consists of 7 hours sleeping, 7 hours of office work, 4 hours of light home activities, 4 hours sitting, 1 hour standing, 30 min of driving and 30 min of walking at 5 km/h), then applying these bits to an incredible chain of assumptions and estimations, to demonstrate that fat people (and not coal-fired electric plants or cow farts) are the chief cause of global warming. One of their assumptions, for instance (made, again, without corroborating data) is that fat people, being lazy, travel in cars far more often than skinny people, and that, because they are fat, they purchase very large cars that guzzle a lot of gasoline. Their startling conclusion is that we have the obese to blame for melting the ice caps, killing the polar bears, flooding the seacoasts, and turning our farmland, forests and fields into hot, dry, desert. From this analysis, anyone with a cheap telescope can only conclude that Martians, when they existed, must have been very, very fat.
An equally astonishing piece of scientific analysis appeared in the New England Journal of Medicine in 2007, proving that obesity is contagious. This study actually received a fair amount of media attention when it was published (though we have not heard much about it since, one hopes out of embarrassment).
This work came from the studios of the famous Drs. Christakis and Fowler, who have embraced a software package, comprehensible only to themselves, that churns out complex images of “social networks,” from which they can derive all manner of heretofore unimagined associations.
Using data from the venerable Framingham database, these pioneers combed through old records for information about the body weight, relatives, and social contacts of individuals who were enrolled in this famous study. They then used their esoteric computer modeling software to create various “animations”depicting the evolving social relationships of the subjects, and the development of obesity, over time. From their own description of their procedure, they iterated their animations numerous times, adjusting their baseline assumptions each time, until they had produced the results that seemed to make the most sense to them. The Scholastics again would be proud.
To summarize the findings they settled upon: A person is far more likely to be come obese if a friend becomes obese, even if that friend lives hundreds of miles away. (This finding is really quite remarkable, considering that the only other natural force that acts on bodies instantaneously and at a distance is gravity. This newly discovered force that produces obesity at a distance – shall we call it obevity? - will have to be incorporated, with great difficulty no doubt, into the Grand Unification Theory now being sought by physicists everywhere.) Remarkably, the same effect was not seen when close neighbors became obese, or even (to such a great extent) when family members became obese. Furthermore, if the friendship is mutual (that is, if the fat person considers you a friend in addition to you considering the fat person a friend), the odds of your becoming obese triples. And worse yet, this study shows that even if you wisely avoid the company of fat people yourself (in an attempt to remain acceptably svelte), fat people who are acquainted with your acquaintances may still have an impact on your BMI. That is, you don’t actually have to befriend a fat person to be affected; befriending a skinny person who has a fat friend is enough to make you fat. Obesity, then, is a particularly insidious contagion that propagates itself throughout the social network even without direct contact. The obvious conclusion from all this (though mercifully unspecified by the authors) is that obese people, being such extraordinarily virulent vectors for such a dread condition, ought to be culled out from the herd and, perhaps, concentrated in special camps.
One should not have to read any of the critiques that were subsequently published regarding the methodologies used in this study (including one written by your humble author) to understand that the study and its findings are absurd.
The remarkable thing is not that silly studies like these are being produced – such is always the case – but rather, that the editors of prestigious journals of science and medicine are seeing fit to publish them. This fact alone is sufficient to demonstrate just how deeply imbedded in our polity is the project of demonizing the obese.
The very publication of such studies suggests that the obese are rapidly becoming the witches of the 21st century. And when you are faced with witches, you are obligated to do everything in your power to stop them while you can.
It is easy for those of us living hundreds of years after the Salem Witch Trials to condemn (or at least laugh at) the folly of those olden and less sophisticated times. I will simply point out that burning witches is an evil act only if you don’t believe that witches are real. If you, supported by all the respected authorities of the day, believe that real witches are present in the community, and that they indeed are capable of producing extreme harm to innocent individuals, surreptitiously and at a great distance – kind of like the obese – or are capable of reducing the entire community to a hot, dry cinder – also like the obese – then roasting them slowly over a pile of green faggots is at least reasonable, if not the only responsible thing to do.
By their own selfish actions, actions which threaten the collective far more than merely themselves, the obese have become fair game for whatever manipulations our government can devise to cause them to either lose weight, or pay for their sins.
And especially now that we have so many programs and policies aimed at preventing obesity – putting apple slices in Happy Meals, publishing calorie counts in restaurants, being lectured at by First Ladies and skinny movie stars, &c. – we can reassure ourselves that anyone who still chooses to remain obese despite all this abundant assistance must be especially contemptible.
Our actions against the obese may begin with simple taxes on the calorie-laden foodstuffs particularly favored by fatties, but the sky’s the limit. A special “carbon tax” based on their BMI would be legitimate, for instance, since it will always cost a lot of energy to move a fat person from point A to point B, whatever the mode of transportation. The periodic mandatory public “weigh-ins”such a tax would justify would serve the useful purpose of public humiliation, an important incentive to weight loss. And it goes without saying that it would be fully justifiable to simply withhold certain healthcare services if one is deemed too fat. Under the more enlightened culture of Great Britain, the National Health Service (the model to which Dr. Berwick and other of our current healthcare heroes openly aspire), the obese are now being removed from the waiting lists for medical services.* By virtue of their obesity (and the lack of social responsibility their obesity reveals), fat people have forfeited their equal access to healthcare.
*Removing fat people from the NHS waiting lists has at least two beneficial effects. It punishes them, of course, for their selfish refusal to maintain their own wellness. But it also reduces the long waiting lists that exist in Britain for medical services, closer to the target waiting times which the government has been promising its citizens for decades.
Demonizing the obese, of course, is its own reward. But it also provides several critical precedents that will come in very handy sooner or later.
Ignored in the general disgust we profess toward the obese is the fact that, for the large majority of people who are seriously obese, their obesity has a very large component of genetic predisposition. For such individuals maintaining a “normal” body weight is virtually impossible. So when we learn to demonize the obese, we are also learning that wellness is your duty even if your genes (or some other force that is largely beyond your control) mitigates against it. In this way we are setting a very useful precedent that will allow us to discriminate against other groups of people who have genetically-mediated medical conditions.
Those who may wonder why this is a big deal need to go back and study the original Progressives, for whom some form of genetic purification was an indispensable step toward achieving societal perfection. This was true not only for notorious eugenicists such as Woodrow Wilson, H. G. Wells, George Bernard Shaw, and Margaret Sanger, but also for the kinder, gentler Progressives we generally revere even today, such as Theodore Roosevelt, Winston Churchill, and even Mohandas Gandhi. This sort of thinking fell out of vogue, for obvious reasons, after World War II. So it is no longer polite to talk openly about genetic cleansing.
But discriminating against people who have a genetic predisposition to gross obesity (in the name of achieving an optimally efficient healthcare system for the purpose of cost saving) would be a start.
Once the Central Authority sets into motion the laws and regulations needed to control the behavior of fat people (or people who might otherwise become fat), they will have established the mechanisms and techniques (and the justifications) for controlling all of the private behaviors that might be useful to control, for all American citizens.
The obese, therefore, are the perfect prototype. Thanks to them, we are teaching ourselves that it is right and proper to disdain any individual who is leading less than an exemplary life. Many of the people whose lifestyles are suboptimal, unlike the obese, may be relatively difficult to spot. But at the end of the day, they will reveal themselves in the ultimate manner – they eventually will fall sick.
And by their diseases we shall know them.
For the past several years, our infallible healthcare experts have been busy declaring more and more illnesses to be “preventable.” And if an illness is preventable, and an individual fails to prevent it – well, what more do you need? That person has obviously failed to perform their sacred duty to society, and has forfeited any claim to the healthcare we more deserving people can expect.
The list of illnesses which are officially preventable now includes coronary artery disease, heart failure, kidney failure, diabetes, stroke and many kinds of cancer. And recently Alzheimer’s disease was added to the list.
It is possible that in a decade or so, if you acquire an illness from this growing list of “preventable” medical disorders – especially if your annual wellness checks reveal that you have gained weight since high school, or you habitually fail to exercise at least 90 minutes per day, or that you imbibe less than one or greater than two alcoholic beverages per day, or you commit any one of a hundred other lifestyle sins – you may be triaged to some sort of Tier B healthcare, as in Great Britain. Tier A, of course, will be reserved for people who obviously care more than you do about wellness, and about their duty to society (and also, obviously, to the sundry experts and political leaders who are critical to the success of the collective).
Just as obesity does today, the overall state of your health will demonstrate your true commitment to the perfect society to which we all aspire. For, when it is your duty to maintain wellness, the very fact of your illness reveals a grave dereliction of duty.