We tend to find the patterns we are seeking. The image of Jesus in a grilled cheese sandwich comes to mind. He has, apparently, turned up in shower mold as well. Those might be miracles, but I am guessing they are more like the constellations: a bit of vague resemblance to something, a dose of wishful thinking, and a hearty application of predisposed imagination. Seriously, other than the dippers, big and little -- can you actually see any of that stuff up there in the night sky? I blame it all on Greek wine and insomnia.
But I digress. We find the patterns we are seeking, and when I write -- as I mostly do -- about losing weight and/or finding health, people find in my writing the patterns they love to love, or love to hate. This may relate to what kind of yogurt you prefer, but we'll come back to fermented dairy products in my next column. The divisive topic du jour is personal responsibility.
Divisive it is. The role of personal responsibility in the management of health and weight has long attracted both professionals and everyone else to choose a place in opposing corners. In one corner is the group that invokes personal responsibility as the answer to all ills. We need no regulation, we need no environmental reforms, we need no food control, or gun control, or any kind of nannying. We just need to make good choices.
In the other corner are environmental determinists who, at the extreme, might wait around for someone to spoon feed the quinoa and escort them to the gym.
My prior column wasn't about personal responsibility at all. I was addressing our medical myopia, the tendency for our culture to see medical problems and apply medical solutions to matters of culture. Learning and acquiring skills confer benefits we can apply for a lifetime, and share with those around us. An adage comes to mind: give a man a fish, and he'll eat a meal; teach a man to fish, and he will eat for a lifetime. You can choose any variant on this theme you like. Give a woman a bike ride, and she'll get to a place; teach a woman to ride a bike, and she'll get everyplace. You get the idea.
That was my point. Treating obesity with bariatric surgery is effective, and all too often necessary. But nobody learns under general anesthesia -- and our culture could prioritize other approaches. Enough said.
The comments made in response to that column are the basis for this one. Some people cheered me for placing an emphasis on personal responsibility -- but as noted, I wasn't writing about that in the first place. Others, who seemingly had not read the column at all, accosted me for blaming the victims of obesity, something I have in fact opposed vigorously throughout my career.
But since Jesus has been found in grilled cheese, and personal responsibility has been found in my columns even when I'm not writing about it, I would like to set the record straight -- again- with a little help from Spiderman.
I trust you've seen the Spiderman movies, and know the axiom they memorably deliver: "With great power, comes great responsibility." Anyone pausing to think about this even a little recognizes that if there is such a correlation between power and responsibility, it has to run both ways. With vanishingly negligible power comes vanishingly negligible responsibility. In fact, we all know and believe this already, because we apply just such thinking to newborns. They have no power, and aren't responsible for anything. We raise children to take on more responsibility as their capacity to do so evolves.
And so it is that public health can, and should, embrace the Spiderman principle, but place equal emphasis on the implied corollary: before we can ask or expect anyone to take responsibility, they must be empowered.
Imagine, for instance, that your task were to climb Mt. Everest. For starters, it's difficult and costly just to get there from here, and not everyone has those resources. That matters. Further, wanting to get to the roof of the world won't do. You need at least entry-level mountaineering skills to stand a chance. Here, as elsewhere, power is prerequisite to responsibility.
But now imagine that the task of climbing Everest, and being personally responsible for reaching the summit, is compounded. You don't just have the ascent, the ice, the cold, and the lack of oxygen to deal with. You have to overcome Sherpa cabals hiding behind outcrops and pelting you in the head with snowballs every chance they get. One response to this is: just suck it up and deal with it. But it doesn't seem a reasonable response.
With regard to health and weight control, we have exact analogues to projectile-hurling Sherpas. We have known for years, and been reminded recently, that Big Food hires Ph.D.'s and uses advanced technologies to engineer foods that are, for all intents and purposes, addictive. We could call on every soccer Mom and grade school kid to just deal with it- but come on! This is a contest that makes David and Goliath look like they were in the same weight class. And lest you think that Big Food's mischief is a thing of the past, we learned only recently that the very soda companies that got a photo op with the First Lady for agreeing to promote water intake had devised strategies to discourage water and encourage soda.
There is a point at which invoking personal responsibility to deal with a contrived array of obstacles is both benighted and callous. Yes, everyone should try to eat well -- but they should not have to overcome the ingenious manipulations of highly paid mercenaries conspiring against them to make it so.
The other problem with endless harangues about personal responsibility is that they imply the supply is limitless. Far more realistic is that humans have some basic endowment of personal responsibility, and it's pretty much the same as it ever was. We have no scientific evidence whatsoever to suggest that the current crop of Homo sapiens is less endowed with personal responsibility than every prior crop. We certainly have no suggestion in either science or sense that today's 7- and 8-year-olds are less personally responsible than every prior cohort of 7- and 8-year-olds. So if obesity and chronic diseases related to lifestyle are now rampant among adults and children alike despite a constancy of personal responsibility, it suggests the problem is more all around us than within us. The body politic has responsibility, too.
It's all well and good to suggest that people lift themselves up by their bootstraps, but not everybody has boots.
As far as I'm concerned, we have failed to take a personally, and publicly, responsible approach to the matter of personal responsibility. Who decided in the first place that we are obligated to choose between this corner, and that corner? We are not. The common ground is in the middle.
What I do with my feet and my fork is, ultimately, up to me. No one else is going to exercise for me, or eat broccoli on my behalf. So, too, for you -- and everyone else.
But the choices any of us makes are subordinate to the choices we have.
We could insist that people make good choices despite having bad ones. We could wring our hands and bemoan the cruelty of having to make choices at all. If I may be blunt, I think these are competing visions of la-la-land.
In the real world, we need to have good choices to make good choices, and even when we have good choices, we still have to make them our own. The body politic should pave the way, not erect barriers -- but there is no reason to expect we will be carried. We all need the will to walk the walk, provided there is a way.
Enough nonsense about personal responsibility. The choices we make are subordinate to the choices we have. For public health to advance, we must choose to renounce our opposing corners. We must choose to come out and shake hands. We must choose a culture in which we collectively ensure we have good choices, and then -- and only then -- take personal responsibility for making the most of them.
Dr. David L. Katz; www.davidkatzmd.com