Not Just Personal Responsibility


Off and on during the current health reform debate, politicians, leaders and pundits have raised the issue personal responsibility. For instance, take these comments from the John Mackey, the CEO of Whole Foods:

“…many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.”

That is a refrain many of us who think and discuss American medicine are used to hearing.  In fact, I wrote an article over a year ago in Salon emphasizing the role of individuals in taking care of their own health.  That being said, though, I think (especially after having read my readers’ comments about that piece) the view doesn’t take into account the socio-economic factors that pressure many Americans into chronic illness.

Let’s look at obesity as an example that illustrates this.  Almost one-third of adults and children are obese, a problem that costs us $100 billion dollars a year.  In California, where I live, our State Controller estimates that “the economic cost to California of adults who are obese, overweight and physically inactive is equivalent to more than a third of the state’s total budget.”

Those are the facts, and as Mackey so obviously says, a proper diet and exercise can help to prevent obesity.  But for many, that’s not so easy.

To illustrate what I mean, consider the following experiment:  a while ago, I decided to take a trip to the grocery store with $40. I spent half of that money on fresh, healthy foods and the other half on processed foods.  I took my grocery bags home and counted up the calories per dollar that I spent on both types of foods.  For the healthier choices, I got 140 Calories per dollar; for the processed foods, I got 370 Calories per dollar.

That little experiment has real-world implications when you think about middle class families, with two (or one or zero given our current unemployment numbers) working parents, trying to make ends meet.  Even people living paycheck to paycheck know what food choices are good for them. But if you’re one of the millions of families just scraping by, popping a couple of DiGiorno pizzas in the over for dinner is cheap and calorie-laden enough to soothe your hunger pangs. It also leaves one less battle to fight with your kids between getting them to finish their schoolwork and getting them ready for bed.

Add the consequences of my little experiment to some other factors, like the lack of access to fresh foods in poorer communities (Mr. Mackey, do you have any stores in low-income areas?), or a lack of safe places to get out and exercise, and you can see that prevention has as much to do with class, income, and communities as it does with personal responsibility.

Dr. Rahul Parikh is a Pediatrician in the San Francisco Bay Area and a frequent contributor to Salon.com and THCB. Dr. Parikh practices with the Walnut Creek Medical Center and Kasier Permanente.

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12 replies »

  1. Great commentary! I especially liked how you talked about your experiment with going to the grocery store and seeing how far your “healthy food dollars” stretch. It’s easy to blame the individual, but you really explained how socio-economic factors, like the retail food environment an individual lives in, has a huge impact on what he or she actually eats. Thanks!

  2. You should know, that Anacostia in DC does not even have a single grocery store–only convenience stores.

  3. “The bottom line is education, if people are aware of the implications they may be having on the healthcare system and on themselves there is a chance that they might do something about it.”
    Fat chance. Where are they getting their education, from mini mart shelves, gas station food, TV ads, and the psychologically designed grocery store shelves and food packaging. Many inner city and rural people don’t have much choice for alternate food sources as large grocery chains or alternate food stores don’t locate there.

  4. Surely if US healthcare is suffering at the moment due to personal responsibility, or lack there of, then it would continue to suffer following a healthcare reform. It is a change in the habits of citizens that is needed, not a change in the system that looks after them.
    I wouldn’t agree that socio-economic factors determine the health of many americans, especially when it comes to obesity. There is always a choice, even if you do have little money, live in a bad area, or come from a lower class background. Besides its not always people that come from a less fortunate background that suffer from obesity, over 30 percent of americans are obese, and this cant be blamed solely on people from poor communities.
    The bottom line is education, if people are aware of the implications they may be having on the healthcare system and on themselves there is a chance that they might do something about it.

  5. Why has no one mentioned the elephant in this room, which is that as presently structured, our health care system has exactly zero incentives to get people to lose weight or exercise? Primary care doctors don’t get paid for nagging, or for hiring a nutritionist or nurse practitioner to work with patients on changing their diets or lifestyles.
    Specialists get paid huge bucks for fixing the resulting kidney failure, heart attacks, high blood pressure, etc. And low-income people who can’t afford fresh produce or health clubs, and live in neighborhoods without safe access to outdoor exercise, have the least access of all.

  6. I think overall it would be easier to reform health care than to get Americans to change their eating habits.
    I’m thinking back. Are any of those actors in the DiGiorno commercials obese from eating too much pizza? How about some truth in advertising.

  7. I did an article on The Healthcare Transformation” (I think) or wrote in comments here along the same line. However I will take a step further.
    It takes a village to have a healthy life style. So there are more than personal elements. But personal responsibility can make a lot of things happen. Crux of your health is your body and your mind. Need to eat well, live a life where you or the village forces you to active, and most importantly you have a social life.
    In our society, it is the social element that is missing. For it to change back, we would need to go through social reengineering or transformation. We now work till 6-7 PM, come home and we are done. There is pretty much no time to have that village life.
    I come from a village. It is entirely different social structure….For those very protective of privacy, it may not suit as you are rarely alone. But they do have healthier life. This is despite the fact that most of the villages have no running water and electricity and sanitation……….
    Imagine the culture where you do not have to make an effort to see your neighbor….it just happens daily.

  8. Usually, the right wing folks stress personal responsibility, while the people on the left (like Peter above) point out structural imbalances supporting wrong choice patterns.
    I’d say both are right. If you want to fight the horrible obesity pandemic, you have to promote cultural change (against the sedentary lifestyle, against sugared sodas and and the worst other processed foods), take away incentives like corn subsidies and allow insurance companies to give meaningful rebates to 9near) normal weight individuals and people demonstrably loosing pounds.
    It’s always stressed that our cultural ideals in the US is the anorectic model – true, but this is the dream ideal; the reality is that being morbidly obese is a very common state.

  9. “For the healthier choices, I got 140 Calories per dollar; for the processed foods, I got 370 Calories per dollar.”
    That’s because the processed foods are subsdized. Corn subsidies produce cheap sugar (HFCS), cheap beef (feed lot production) and a whole range of processed corn food products. If you want to know why we’re fat read, “The Omnivore’s Dilemma” by Michael Pollan. It’s not about OUR culture, it’s about Corporate culture.

  10. I think your points ring true regarding the degradation of the ‘modern’ diet to calorie-dense foods which by definition are low-cost/calorie. Unfortunately these food items are based on processed sugar, highly milled grains and significant additives, all extraordinarily unhealthy, diabetogenic, and inflammation-promoting. Read Gary Taube’s excellent historical review in his thought-provoking book: Good Calories, Bad Calories
    Unfortunately in addition to the financial aspect such habits are both socially and ethnically ingrained making change extremely difficult. We as health care providers do not always help either, witness the promulgation of essentially unproven dietary dogma such as the ADA diet, and low-fat=low cholesterol recommendations. Mounting data has suggested we are likely significantly off base with such treatments.
    Nonetheless, the only way this can change (short of dictatorship!)is by improving personal responsibility. There must be an individual or cultural connection to the value that is achieved, whether it is ‘feeling better’ or saving money or longevity….But actual success will be difficult nationwide.