A Big Fat Crisis (19 page)

One of the largest disagreements in design had to do with the size of the sewer pipes. Chadwick, who was deeply involved in the creation of sanitation systems, wanted narrow, thin-walled pipes in which sewage could flow quickly; narrow pipes were also less expensive. Charges of corruption and/or incompetence were made by Chadwick and a handful of engineers, particularly when sewer system designs chosen for adoption were more costly than what they had proposed. However, for Chadwick’s design to work, citizens had to be mindful of the materials they dumped, as large objects, hair, grease, and grit would clog the pipes. Chadwick wanted a large-scale education campaign to train the public to use the new systems properly.

Most engineers, however, wanted more expensive, wider pipes and insisted that designers had to allow for accident and error. They thought it foolish to consider the frequent breakdown of narrow pipes avoidable, if it wasn’t avoided. In addition, larger pipes could also handle rainwater and other detritus that flowed into sewers. Thomas Page, an engineer, noted, “As the population cannot be hastily fitted for the sewerage, the sewerage must be fitted for the population.” He thought it unrealistic to expect people to adhere to the meticulous standards necessary to prevent narrow pipes from blocking up. Ultimately, the wider pipes did prove more effective.

The Sanitary Revolution quickly expanded beyond sewage disposal and clean water provision. One of the first measures undertaken to enforce new sanitary codes in England was the appointment of sanitary police by local towns and cities. The sanitary police were inspectors of nuisances. Their very presence and mission constituted an assault on private property rights, while elevating the protection of the common good.

The decisions about which nuisances to tackle and which to ignore were sometimes arbitrary. Sanitary police could handle accumulation of filth, bad drains, smoke, unsound or overcrowded dwellings, insufficient privies or water closets, unclean workplaces, and a range of other unhealthy conditions. For the most part, nuisances were summarily addressed and legal action was avoided. The stigma and humiliation associated with violating sanitary standards made it less likely for people to be outraged enough to assert and defend their rights to keep their private property in whatever condition they wanted.
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The Sanitary Revolution spurred a complete transformation and growth of government, creating the field of urban planning as well as departments of public works, transportation, and parks. Interestingly, in the United States, urban parks were initially created as a means to designate areas where dumping would be prohibited. Subsequently, parks were promoted as places where people could go to recreate, relax, and breathe fresh air.
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Although our understanding of disease and human behaviors has significantly advanced since the 1800s, today we are at a similar crossroads. Just as Chadwick and the British Boards of Health faced epidemics of infectious diseases, we are facing unprecedented epidemics of obesity and chronic diseases, and there is a cacophony of voices with conflicting ideas about how to address the problem.

My analysis of what we need to do builds on the public health principles that identify the conditions in which people live as the source of both health and disease. Thomas Page’s words of two centuries ago are apt for today: because the population cannot stay fit in the current
high-risk environment, we must change the environment to fit people’s needs.

To protect our population, we have all kinds of standards that we expect everyone to adhere to when life and limb are at stake. Think of the extensive building codes and regulatory process associated with constructing a house. We have rules governing the types of bolts and screws, the allowable depth, width, and height of the steps in a flight of stairs, as well as the distance between the vertical bars of a stairway guardrail. All these regulations are specifically designed for safety—to prevent buildings from crumbling and people from tripping or falling.

If we can regulate the design of features that protect people from injury, why can’t we regulate the malleable factors that lead to chronic disease?

Public health has an important—but admittedly limited—role in stopping the obesity epidemic. It’s not the role of public health to force you to eat healthier food or compel you to exercise. However, I believe it is the role of public health to make it easier for us to obtain a healthy diet and to be physically active by minimizing the risk factors that undermine and overwhelm us. I’m not splitting hairs: there is a big difference between regulating people’s behavior directly and regulating the environment in which we live. It is not appropriate, for example, for the government’s public health department to stop you from eating a candy bar every day if that’s what you want to do. But it is appropriate for the government to protect you from marketing practices that force you to confront a candy bar every day.

Our approach to pornography is instructive. We don’t ban it, but we restrict its availability. It is not on every street corner, at every cash register, or in vending machines. If it were, it would be impossible to ignore. If we had to see pornography everywhere we went, no doubt our ability to think about anything other than sex would be challenged. Food can be a little like pornography.

There are two ways of thinking about how much regulation we want in our lives. The current approach with respect to the food environment is “You’re on your own”—there is a minimal amount of interference in the way food outlets operate, except with respect to hygiene.
The burden is on consumers to figure out our nutritional needs by ourselves, but the deck is stacked against us.

At the opposite end of the spectrum, “We are all in this together,” public health departments could establish benchmarks and standards that would require businesses to ensure that the food they serve will not increase people’s risk for disease, at least not without the customer’s full awareness and consent. New regulations could enhance the food environment so that it would favor consumer health.

“We are all in this together” is how we currently handle water, another commodity that everyone needs to survive. Nearly all the water available to the American public is potable. If it isn’t, it is clearly labeled so. We have established rigorous systems in which we test the water supplying most localities on a regular, if not daily, basis to make sure there are no contaminants that could increase the risk of cancer or lead to potentially deadly infectious diseases, like cholera or
E. coli
. Rich or poor, everyone gets the same water quality. Although the system is not perfect—there are instances of groundwater contamination that must be mitigated, as well as many Americans who have to get water from their own wells (usually in rural areas)—most people use municipal water from the tap, either plain or filtered, and do not suffer any ill health from its consumption.

In contrast, in countries where most available water is not potable, anyone who wants safe water to drink has to take arduous steps to make it so—boiling, filtering, and safely storing it. In such societies, rates of infectious disease and childhood mortality are much higher than they are in the United States, partly because for too many people it is too burdensome to take all these steps. Even having a few people who fail to comply with sanitary standards can spread disease to many.

Think how onerous it would be if we did not have a system of safe public water and there were hundreds of unregulated companies selling water, each claiming their product was superior or tastier. How could people be confident that they were not going to get water that would make them sick? After all, water quality testing is not something most laypeople can easily do. What would we do without a trustworthy independent group that could certify the water as safe?

We have long passed the time when anyone would consider it reasonable
for the government to merely issue guidance for “Healthy Water Standards” listing all the most common carcinogens, toxins, viruses, bacteria, and parasites, and the maximum tolerable amount we could consume per week. Imagine the absurdity of allowing companies to sell water that had contaminants in concentrations such that it would be easy for consumers to be exposed to amounts greater than recommended by the Healthy Water Standards. Too many people would not be able to make wise choices in a marketplace with all manner of water qualities being sold, if the impurities on the product label were listed in parts per billion or milligrams per deciliter and people had to compare these amounts with the recommended standards on their own initiative.

Yet this is the situation in the modern food environment. The burden for avoiding unhealthy foods and assembling a healthy diet is entirely on the individual. The requirement for calculating calories and essential nutrients for an optimal diet is beyond the capacity of most, and it is just as demanding, if not more, than if we all had to figure out individually which water in which quantity was safe to drink.

For a healthy diet we need to regulate both the quality and the quantity of the food we eat. But the glut of food in America is a primary factor limiting our ability to do so, because it promotes intense competition in the food industry and aggressive marketing. America produces nearly twice the calories that people need—about 3,800 calories per person per day.
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In contrast, Japan does not produce as many excess calories (only 2,558 per person a day) and does not have a substantial obesity problem.
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The excess availability and consumption of calories are now significant contributors to climate change. The production, processing, and transport of foods lead to carbon emissions that contribute to global warming. About 40 percent of all food in America is thrown away, and 97 percent of food waste ends up in landfills, where it decomposes to form methane gas, which has a global warming potential twenty-five times that of carbon dioxide.
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Food is estimated to contribute more than seven tons of carbon emissions per household per year, and about half of that is attributable to meat and dairy consumption. Furthermore, it is estimated that merely eating less (e.g., reducing average
consumption from 2,500 to 2,200 calories per day) could substantially reduce household carbon emissions and save the average American household $850 per year.
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The largest environmental strain from food stems from meat and dairy products, for which the production and consumption contribute to 18 percent of all greenhouse gases.
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Animal protein production requires eleven times as much fossil fuel as vegetable proteins and a hundred times more water.
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Although the US Department of Agriculture’s 2010 Dietary Guidelines for Americans recommends no more than 1.8 ounces of red meat per day, Americans consume 37 percent more than that.
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Ironically, humans get no physiological benefit from eating too much meat as compared to other foods. Our bodies can only absorb and use a limited amount of protein—we cannot store it the way we do fat, and so we simply excrete whatever we don’t use. We are literally flushing more than half of the protein we consume down the toilet.

Although the goal of improving health is sufficient to justify public action, the monster storms, the rising oceans, the droughts, and all the unusual weather changes we have been experiencing over the past few years should provide an incentive beyond stopping obesity to rethink how we regulate the food environment. The suggestions in the next chapter squarely address how we should target the environment to support individuals who would choose health over heft.

9

A Safer Food Environment

Have you ever wondered why bars from New York to Los Angeles serve beer in twelve-ounce servings, wine in five-ounce servings, and liquor in 1.5-ounce shots? It’s because beer, wine, and liquor all contain different concentrations of alcohol, so the standardized serving of each contains 0.6 ounce of pure alcohol. Standardized serving sizes ensure that a drink is a drink is a drink: 0.6 ounce of alcohol, no more, no less, no matter what you choose to imbibe.

Compare that to food, where serving sizes are all over the map. A double cheeseburger at McDonald’s has 440 calories and a medium fries has 380. At Carl’s Jr., a Super Star Cheeseburger has 940 calories and a medium fries has 430. At Denny’s, a cheeseburger and fries is 1,400 calories. And at Chili’s, the burger-and-fries platters range from 1,310 calories for the Oldtimer to 2,290 calories for the burger with ancho chili BBQ. Even with calorie labels on menus, you’d have to be pretty good at math, algebra, and geometry to figure out how to divide up your food in order to eat just 640 calories, the amount that is recommended by the Institute of Medicine for a single meal for the average person trying to maintain a normal weight. The IOM assumes adults eat three meals and one snack to obtain the recommended average of 2,000 calories per day.