Dependence, Independence, and Offering Care
This is a day for Americans to celebrate independence. Though the holiday marks independence from a colonial power, Americans invest a lot in a broader concept of independence. Dependence on others for many things – including care for health – is essential for strong communities, and yet Americans celebrate a spirit of independence. It wasn’t artful politics, but Secretary of State John Kerry expressed the idea in 2013:
“In America you have a right to be stupid – if you want to be. And you have a right to be disconnected to somebody else if you want to be.”
This conflict is inherent in public policy. We protect the independence of individuals while building communities where dependence and care for neighbors is a fact of life. In health policy, this tension is unavoidable.
Dependence and Independence in Obesity
The conflict between dependence and independence is especially strong when the subject is obesity. Thinking that obesity is simply a matter of individual choice and responsibility is a dead end. People live in communities where they have limited choices about what to eat and the patterns for their daily lives. Yes, we all make choices. But we choose from a limited menu of options.
When the menu serves to promote obesity, its prevalence grows. For decades now, the menu has kept evolving to promote ever more obesity. This is not a failure of the individual with limited options. It is a failure of a community that offers up an unhealthy menu of choices.
Screening Without Caring
Despite this, blame accrues to the individual for obesity. Thus blame provides a rationale for poor access to care. Those people made their choices, so they must live with the consequences. So says one school of thought.
Another line of thinking dresses in more compassionate garb. Prevention must be the focus because there are just too many of those people with obesity to provide medical care for them.
The result is that much has been done to screen and point the finger at people with obesity. But little effort goes into offering care.
The Ethics of Prevention and Care
Hunter Smith, Joy Piotrowski, and Stephanie Zasa describe an ethical failure in implementing preventive health policies for obesity. They write in the July issue of Pediatrics:
If the American Dream is one in which individuals of any socioeconomic stratum or geographic background have the potential to successfully pursue their goals, then we are betraying this dream by leaving the inequities of childhood obesity unaddressed. This point becomes particularly pronounced after the realization that we have USPSTF-recommended (i.e., evidence-based and effective) screening and preventive interventions for this disease, but that these services remain inaccessible or limited for many of the populations who need it most.
This is a uniquely American failure. But it is one that other countries emulate. We need a change in direction.
Click here for the paper by Smith et al and here for a companion commentary.
Native Americans on Horses, painting by August Macke / flickr
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July 4, 2021
July 04, 2021 at 3:54 pm, Allen Browne said:
I find a “muddlement ” here. The recommendations were to screen and then treat those affected by the disease of obesity with specific resources and a minimum intensity. It seems to me this is identification of those with the disease and then treatment. This is not prevention of the disease. You can’t prevent a disease someone already has. But the inequities are very true. We know how to identify the disease and we have ever improving ways to treat – way beyond what the USPSTF was able to study. But we don’t recognize internalized bias and it’s consequences in the families and children with obesity. We don’t recognize the bias and stigma the healthcare providers, the payers, the policy makers, and the public exhibit every day. Without education about obesity as a disease for all these groups, we are going nowhere. Because of lack of knowledge about obesity as a disease, we continue to not have families demanding care, not have providers referring patients for care, not have payers providing financial support for care, and not have policy makers realizing the approaching moral and economic disaster that is looming.
The paper by Smith, et al, has some good ideas and no depth.