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Raise Your Hand if You Want to Be Sick – Voluntary Illness in a Time of Personal Responsibility

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden Lundgren
February 19, 2018

The 71-year-old President of the United States recently received an excellent health report. That is good news. President Trump is known for his affection for a McDiet and his aversion to exercise. For many Americans, the state of the President’s health seems both unexpected and unfair. The examining doctor explained it as a matter of good genes. But geneticists have become painfully aware that genes are not as determinative as we thought — “junk DNA” is not junk, what happens to one gene affects others, even that if our grandmother smoked, we can be affected too.

That explanation is discouraging, and it is directly antithetical to the popular belief that we are largely responsible for our own health. While this belief may give us a sense of control, it is true only to a very limited extent. Life expectancy in the developed world went from well under 50 years at the dawn of the twentieth century to 70 – 80 years in the 117 years that followed. But very little of this achievement came from individual efforts. It came from a combination of public health efforts and improved living conditions. It came from ensuring a pure water supply, cleaning up dirty air, improving the food supply, enforcing building and safety codes, regulating prescription drugs and implementing mass immunization programs. It came from unexpected sources like the development of train travel. Why? Trains could improve diets by making fresh produce available during northern winters. It came from providing free public education. Better educated populations are healthier populations.

The direct government intervention that brought us the most significant population health gains in human history have given way to a shift of responsibility to individuals. But, in many important areas, government not only fails to aid individual efforts, it makes them more difficult. For example, we expect the government to see that we have safe water coming into our homes while at the same time, the government directly fosters policies that support the soy/corn monocultures that undergird all the processed food packing market shelves. Government entities are responsible for water that does not make us sick while we ourselves are responsible for resisting government agricultural policies that do make us sick. If we do not go out of our way to resist unhealthy policies, are we then inviting what is called voluntary illness? And how hard are we supposed to try?

I had a friend who was at high risk for diabetes. Certainly prudence in diet and exercise was appropriate. But, my friend’s whole life was dedicated to lowering her risk. Every morsel of food was evaluated. A long program of exercise had to be completed every day — no days off. I don’t know if she did develop diabetes, but I have to ask — If she missed a day of exercise, would she have been responsible for her own disease? Two days? A year? I knew her before the development of all the monitors that can keep track of our steps, our calories in and calories out and all the other apps that can measure our lives. At what point do “healthy” obsessions become diseases in themselves?

With responsibility comes blowback. The worst recent example is what happened when AIDS patients were divided into “guilty” (those infected by sex or needles) or “innocent” (those infected by blood transfusions or in-utero) victims. We do this with lung cancer diagnoses today. We ask, “Did she smoke?” as though a positive answer somehow mitigates the awfulness of the diagnosis.

To what extent do we blame people for their illnesses? We seem to follow the model often applied to the poor. There are the “deserving poor” and the “undeserving poor.” Are there deserving and undeserving patients? And, if so, how do we tell? And what do we make of the President’s bad habits and good health?

What happens to this porridge of biological complexity and moral judgment when it comes to public programs? We have experimented with the individual responsibility model by interventions such as posting calorie counts in restaurants and forcing Medicaid beneficiaries to sign “wellness” contracts with little result. The public health model, so successful in the past, should at the least require governments not to implement programs that make healthy lives harder to live. But, at best, we can return to positive interventions, e.g., taxation and subsidies to raise prices on unhealthy foods and lower them on healthy foods – measures a recent study predicted would save up to 63,000 lives per year. Chile is far ahead of us with an 18 percent tax on sodas, removal of all junk food in schools, severe limits on advertising of such foods and prominent black warning labels on their packaging. So far, food manufacturers have responded by reformulating 20 percent of all their products sold in Chile. We can make it easy to be healthy (clean water) or we can make it hard (markets full of junk food). My vote is for easy. And my opinion as a nurse is that there are no undeserving patients.

Author: Burden S. Lundgren, MPH, PhD, RN practiced as a registered nurse, specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk, Virginia. She has served as a consultant to a number of nonprofit groups. Presently, she divides her time between Virginia and Pennsylvania. She can be reached at [email protected].

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