When I leave the hospital each day I’m hit. First I have to get through the main waiting area thoroughfare at the entrance, the visitors with balloons, patients waiting in wheelchairs. Scruffy beards, polished hair, wrinkles and makeup. Eye contact.

Then the main doors slide open and there’s loud dented trucks, patients struggling to get out of the car. It’s hot. I can smell the asphalt. And as I walk down the hill toward the traffic of State Street, squinting from the sun, I’m accompanied by the exodus: the exodus of scrubs, going home, done with another day of trying to keep the state alive.

The hospital is a difficult place. It’s difficult for me to focus on projects when there are constantly oncoming waves of very stark social dynamics.

It’s a cacophony of individuals, a range of people, no signs for navigation and direction. It’s like we’ve all been thrown in a maze as some sort of crude social experiment.

Passing people down the halls I generally feel a tension, with rushed thoughts:

Who will talk to who?
Who’s going to say hi first?
Who’ll ask for help?
–> And who won’t offer it?
When a patient’s being rolled by, who will yield? Who will barge by?

Going out to more rural parts of the state is important for me. I like to think that it helps me understand “what it’s like” for people to come to Jackson for medical care. Of course I know that I’ll never know what it’s really like, but at least it helps me notice the stark differences that I do see.

The hospital is tough because for a lot of people it’s the end of the road, or very close to it. One thing I am coming to grips with is the multitude of specialties, subspecialities of care, and lots of complex conditions that people may have – and sometimes, not all that preventable.

But others do end up at the hospital with complications after years of alcoholism, years of untreated or undiagnosed hypertension, and living a life in which, for a myriad of reasons, the condition wasn’t ever addressed. Are these things preventable?

For a good many, the hospital is a nice place with air conditioning, reliable food, and a cadre of people to shower you with attention and to listen.

The mismatch of someone’s life and an experience at the hospital strikes me. When people come to the hospital, they’re extracted from their ‘home’ environment and come here subjected to external judgement. It’s obvious they aren’t a part of the hospital system – they look over their shoulder, hoping to make enough eye contact to invite conversation. They wear flip flops and carry overnight bags.

When things happen that even further distance myself from the hospital and the system, I sort of go into a tailspin.

Not too long ago as I was walking down a public corridor, two young blue scrubs were talking loudly to one side of the hallway. As I began to pass by them, another blue scrub passed on my left and before I knew it the blue scrubs were fist-bumping immediately in front of me. Instinctively I stopped walking as none of the blue scrubs acknowledged the generosity I had offered them. I looked down at their fists as their loud talking echoed around me.

Later I thought about the woman I had seen slowly walking, seemingly to nowhere, with legs and ankles swollen to a foot in diameter. I thought about the double amputees sitting outside the hospital, the amputees at the Medical Mall. The men with bandages at the bus stop. The woman who asked me how to get to Children’s Hospital to see the young man’s newly born child, the young man with her who thanked me and to whom I said “congratulations.” The woman who warned me to be careful getting to my car after dark, spoke to a security guard, and asked him to escort me.

I thought about these very limited experiences I’ve had with hospital visitors, and I thought about that interrupting, careless, stupid fist-bump. I thought about the horrible disconnects and I’m still thinking about what we do about them.

“The Most Effective Economic Development Opportunity We Have”

I’m not going to cite publications to make the case that economic development does not come from an economy based on sick people. Yet here we are.The health care sector is the least efficient we’ve got. We know the steep prices the US pays for health care do not yield better health outcomes. Among 34 other developed countries, we rank 30th in infant mortality – one of the best indicators for a population’s health (McCullough et al 2012). The Institute of Medicine estimates that the US has spent $760 billion more than it should for health care, due to high administrative costs, missed prevention, and medical fraud (McCullough et al 2012).

We should not pride ourselves on having a profitable health care industry in the sickest place. In a place where many are dying while others face many challenges to live. There’s this strange obsession with Mississippi’s poor health (and poor everything) but then a focus on strategies used again and again that actually do very little to address the problems that result in poor population health. Not expanding Medicaid is just a symptom of much bigger problems. Critically examining the state’s history is important, but we also have to examine how our health care system itself, today, continues to support old ideologies, old politics, old ideas. From the physical environment, the daily social interactions, to the cultures and teachings. And what these mean and what they result in. The fist-bump is one small, but telling, symptom of these things.

*Blues – Small Town – Deep Forests: The Mississippis we like to see*

So what do we do? I’m trying to figure out if practitioners here really know what it’s like to live with severe medical conditions, to live where these patients may live, and the upset of a visit to the hospital causes to life. I believe there are some who do. And who am I to say otherwise? But is it even possible to really know? And what does the alternative model look like? To begin, it’s a place footed on common ground. And for that, thoughtful strategic steps are needed to lay that groundwork.

Works Cited:

McCullough, Jeffrey C., Frederick J. Zimmerman, Jonathan E. Fielding, and Steven M. Teutsch. 2012. "A Health Dividend for America: The Opportunity Cost of Excess Medical Expenditures." American Journal of Preventive Medicine 43(6):650-654.

Yeah, it’s been a while since I’ve written on here. Lots of things to process and projects begun (but, TBD if they will be finished). When I began my time here at the medical center, I’m almost certain I didn’t think I would become disillusioned by health care’s efforts to “address” obesity. In fact I probably never thought about the obesity “crisis” before this job. Now that’s pretty much all I do.

As I’ve written about before, the obesity rhetoric – particularly on Mississippi – is loud and wild and abundant. The rhetoric that’s heard is all based on the basically the same premise, that consuming an excess of calories compared to those you spend (like money, right?) will lead to a gain (but a bad gain). And the converse is true – those who are seen as holding excess weight surely got that way because of their caloric gluttony.

The doctors feel like it’s their job to fix these people. Their job is to cure bodies. I attended a small conference on obesity, with interested GI specialists and administrators and physicians who are so frustrated with obesity and like the money it costs taxpayers. Insert comic relief with a laugh on this lazy culture in the US we’ve created:

<can’t say how many presentations I’ve seen with this image>

Or what about how gross fat bodies are? Let’s look at images of the failing fatty heart, diagrams of that visceral body fat, and hear about weight-loss regimens that externally drain your stomach with a tube. I just kept looking around at the shaking heads, the heads of clinicians frustrated and tired with noncompliant patients, the fat bodies, the money, the disease, the tired. They’re just tired.

What if the clinicians can’t do anything about obesity? And really, what if they’re not supposed to? Most diet/exercise routines don’t work to help people shed weight, particularly the people most overweight. Actually, more evidence shows that once people reach a certain weight, their metabolism slows dramatically, often preventing further weight loss. Physicians don’t know how to talk about obesity with their patients anyway, and have been shown to have stigma against people who are considered overweight.

Physicians want to change habits. They want people to do what they say: “doctor’s orders.” And this is crucial in most health care situations. But I’m not so sure that it’s obesity they can also get involved in – maybe yes for some individuals, but not for changing populations.

Food tends to be deemed the culprit for the obesity epidemic we see, and the related chronic conditions like type 2 diabetes, hypertension, and dyslipidemia. Really, it’s gotten to the point that this narrative is used (overused) all the time. We’re obsessed with food. It’s perhaps understandable that the narrative began with this, as prescriptive behavior change: drink less soda, cut out trans-fat, processed food; be sure to exercise, drink lots of water; eat only a handful of nuts. Eat small meals 5 times a day. Eat eggs (1 or 2?), eat only whole wheat bread (ok no bread), but avoid the high fructose corn syrup in the bread. Eat quinoa and drink kombucha and only pasture-raised certified beef, but anything else that isn’t easily identifiable, avoid. Avoid limit splurge cheat treat yourself, cut it out, be mindful balance, cleanse nurture…

In the early and mid-2000s we became increasingly aware that not everyone ate the same as each other. The more progressives noticed that more deprived areas didn’t have access to the same quality foods as those who lived in wealthier neighborhoods. These deprived areas also happen to have higher rates of hypertension, diabetes, and obesity. Diet quickly became considered as not only the most modifiable risk factor, but also the #1 reason for the obesity epidemic. We finally started recognizing that there are places with limited access to fresh, good quality produce and other staples – food deserts.

From the series, Weight of the Nation — From the series, *Weight of the Nation*

But what else do deprived areas often have?

Crime
Poorly-funded schools
Lack of access to reliable credit and banking
Dearth of jobs
Proximity to environmental hazards

And what else might people with lower incomes have?

Unreliable electricity and clean, safe water, which makes food storage and preparation difficult (if not impossible)
Overcrowded housing or housing in need of repair, which might have pest and mold control issues
Unpredictable or inflexible employment that limits time and energy often needed for engaging in extracurricular *health* behaviors
Dependents, younger and older, that require extra care

These all matter, yes?

Yet, I continue to hear that the answer lies in teaching people about proper nutrition and exercise, even though we know that education (and sometimes even access) cannot do it alone. There have to be conducive, representative, agency-enhancing environments and routines for individuals to comfortably, want to adopt. Long-term sustainable change requires organic change – through changing norms and values, not simply laws and clinical dictations directed toward individuals. And, these norms of health and wellness may not look the same for different groups of people – and we shouldn’t be afraid of that. Maintaining a healthy lifestyle might not get to include extensive meal prep, it might not include daily selfies at the gym, it may not be meticulous or regimented. Given the regular stresses of life, it might still include a rush to get out of the house each morning and an inability to keep up with all the daily news or trends. It might require not doing it all. Is it still *healthy*?

With all this discourse, about judging people’s food consumption and even food availability as a reflection of human character and worth, we run the risk of denying agency of the people, who are often depicted as wholly subject to their surrounding environments. Julie Guthman (2011) calls out food writer Michael Pollan (2006) for explicitly stating this narrative of the dubious consumer: “When food is abundant and cheap, people will eat more of it and get fat.” And simultaneously we isolate the narrative about obesity to one simply on food, eliminating the possibility for social structural imbalances leading to a propensity to chronic disease.

What I’m coming to learn is that yes, individual diet and exercise are the *most* modifiable risk factors -> because they are the least politically disruptive, and they are easiest to quantify.

Obesity and chronic disease are symptoms of larger problems. In the short run, getting some to change their behaviors might work for a few. But when we’re close to 40%, and among some closer to 50% prevalence of obesity and running high risk for serious conditions like diabetes, bigger, looser policy changes are needed for the bigger change.

And so, I’ve come almost full circle here. At LSE, frustrated by economics, now disillusioned by public health. Just ready to start talking different, start reading a different approach to health. My hope is actually that economics, or sociology, might have some answers. But I’m not convinced it’s medicine, and I don’t think it should have to be.

Works Cited

Guthman, Julie. 2011. Weighing In: Obesity, Food Justice, and the Limits of Capitalism.

Pollan, Michael. 2006. The Omnivore’s Dilemma: A Natural History of Four Meals.New York: Penguin.

Featured image from: https://www.theguardian.com/commentisfree/2014/sep/11/fat-shaming-slim-sanctimonious-cause-obesity-crisis.

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