IMAGE:  April 2003  GRAPHIC:  University of Chicago Magazine
APRIL 2003
Volume 95, Issue 4
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Unexpected Expertise  
Poetic Justice  
Survival of the Richest
Food-Court Press  

Clouding the Issues

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From the President  

Survival of the Richest

John Easton

Allen Carroll



One health factor that traditionally lands squarely in the lap of the individual sinner is obesity. What was once decried as a personal weakness, however, has become a national trend, perhaps “the greatest change in an important variable across the entire population that the nation has ever seen,” according to Arthur H. Rubenstein, dean of the University of Pennsylvania’s medical school, who recited well-known but alarming statistics on obesity. Forty years ago, being fat was a bit odd, something to be teased about. In 1960 only one in four adults was overweight and about one in nine considered obese, with a body mass index (BMI) of 30 or more. (Normal BMI is 18 to 24, overweight is 25 to 29.) Today two in three adults are overweight, and nearly one in three is obese. Still more troubling is the emergence of obesity at younger ages. In 1970, for example, less than 5 percent of teenaged boys were obese; now more than 15 percent are. Although the waistline explosion has hit every societal level, it has had the greatest impact on those with lower socioeconomic status and on disadvantaged ethnicities, such as Mexican and African Americans. Half of all adult black women are now obese, Rubenstein pointed out, many of them morbidly obese, with a BMI over 40.

“So what?” asked Rubenstein, admitting that the medical profession has been slow to address the trend despite a series of studies since the 1970s clearly linking excess weight to poor health, including arthritis, asthma, birth defects, breast cancer, gall-bladder disease, hypertension, and more—especially heart disease and diabetes.

It usually takes about 20 years, said Rubenstein, to progress from obesity to heart failure, an ailment that has increased dramatically in the past decade and continues to rise. But as a specialist in diabetes who has watched that disease ravage thousands of patients, Rubenstein is particularly troubled by the rapid rise of type-2 diabetes, up 61 percent since 1990, including a jump of 8.2 percent from 2000 to 2001, the last year measured. The highest rates of diagnosed diabetes are seen in two already disadvantaged groups: African Americans and adults with less than a high-school education. “Next,” he warned, we can “expect to see more and more people who were obese as children dying of type-2 diabetes in their 30s or 40s,” which used to be considered the age of onset. “This is unprecedented. If any of these predictions are right, we have a serious problem.”

“Just to focus on the costs of obesity seems a little narrow minded,” responded the Harris School’s Tomas Philipson, who noted that obesity can be seen as a result of technological and social progress. First—and hardly a bad thing—the cost of calories has plummeted. “The price of food has dropped, and the percentage of our income that we spend on food has dropped,” said the economist. For the first time, the poor in the United States and increasingly in less developed countries can afford all the food they want and have more food choices than ever before. The bad news, of course, is that many less expensive choices are highly processed, calorie-dense, low-nutrient foods, flavored with cheap sweeteners and artery-clogging fats.

Second—you want fries with that?—people now eat more calorie-dense fast foods because the value of women’s time has gone up, which means wives and mothers no longer have as much time to cook. Between 1970 and 1996 the portion of food dollars spent on meals away from home jumped from 25 percent to 40 percent. Americans now spend more than $100 billion a year on fast food. Such restaurants compete on price and volume, which drives them to offer ever-larger portions of emptier calories. In 1960 an order of McDonald’s French fries, for example, contained 200 calories; now the popular supersize fries has 610.

Third—supersize meets Super Mario—people no longer burn calories as rapidly. “We used to get paid to exercise, to perform manual labor for up to ten hours a day,” Philipson said. Now most people work at a desk, accessed by elevators and e-mail. They pay for the privilege of exercising at a gym three hours a week. “Or they spend that time on something else,” he said, “maybe with their kids”—who often spend their spare time playing video games rather than sports.

In the 1950s, well before the dawn of the social-determinants field, noted James House, director of the Survey Research Center at the University of Michigan, it appeared that antibiotics had conquered infectious diseases. It seemed a triumph for undiluted, laboratory-based biomedicine, which was “openly hostile” to the psychosocial aspects of health.

That triumph was short-lived. The nature of disease was changing. Those who survived infectious diseases began to die, somewhat later in life, from heart disease and cancer. The quick killers, germs, gave way to something slower but harder to stop. Microbes had passed the baton to “risk factors,” like high cholesterol, elevated blood pressure, smoking, and something vaguer still, labeled “stress.” There were initially no drugs to combat these disorders, only protective behaviors. By the 1970s, said House, “risk-factor epidemiology had become a growing concern,” followed by social epidemiology, which implicated things like limited education, lack of social support, and personal and occupational stress as contributors to disease.

IMAGE:  Survival of the Richest

Compared to the complex epidemiology of interrelated risk factors, germs began to look delightfully simple. A microbe launched the battle. Either your immune system, with support from antibiotics, beat it back and you lived, or it didn’t and you died. But as scientists tried to unravel the social and behavioral components of disease, they increasingly realized that there were too many risk factors; they were too mixed up, too complex, and too interconnected to be easily deciphered.

A 1975 study by Graduate School of Business economist Sam Peltzman, PhD’65, highlights the problem. Long before New York passed the nation’s first mandatory seatbelt law in 1984, Peltzman found that even a simple behavior like buckling up can produce unforeseen consequences, with real health risks. Once drivers fastened their safety belts they felt snug, safe and secure, drove faster, and thus had more and nastier accidents. So what starts as a simple, mechanical solution can create a new social problem.

At the conference Peltzman expanded this theory, suggesting similar responses are likely to attenuate the benefits of any medical breakthroughs. Risk taking increased after the introduction of antibiotics, he argued, because people stopped dreading infectious diseases; as a result, deaths from infectious disease regained some lost ground. More recently, interventions such as cardiac-bypass surgery and angioplasty may have reduced the fear of heart attacks, removing a powerful disincentive to obesity. Similarly, the development of effective AIDS drugs appears to have undercut the public-health push for safe sex.

But medical science needn’t give up just yet. GSB economists Kevin M. Murphy, PhD’86, and Robert H. Topel have spent the past few years trying to measure the financial benefits of medical research, what they call the economics of well-being. They began by asking how much people would pay for an extra year of life. Unfortunately, you can’t just buy a few months at a time, like topping off your gas tank, so they had to calculate how much people would value a little extra time, based on the decisions they made about what health risks they would accept in exchange for a better paying job, or how much they were willing to invest in a safer car. It turns out that people value an entire lifetime at about $5 million, more than most taxpayers earn over their three score and ten but less than a malpractice lawyer would request for a client’s loss of a single year. The early years are worth more than later ones—for example, 12 months of being 30 and healthy is worth more than 52 weeks at 50 with angina, but even the senior moments of life are worth quite a bit, said Murphy. “No one wants to live to 65, then die the day they retire.”

Most U.S. citizens, of course, now live well past retirement age, to something approaching four score. From 1970 to 1998, the period Murphy and Topel studied, the average life expectancy for a 65-year-old increased by about 3.6 years, from 15.2 to 17.8. If each bonus year is valued at about $75,000, then multiplied by the U.S. population, around 280 million, the result is a very vast number.

Murphy and Topel were stunned to find that the economics of well-being added up to about $73 trillion for the 28-year study period, or about $2.6 trillion per year—about half of the nation’s gross domestic product. The survival gains for men are greater than those for women, and almost half of the profits are reinvested in medical care, not a bad thing since it provides steady jobs in a nonpolluting industry. But the overall benefits, the authors emphasize, are enormous, staggering, and increasing. “As the U.S. population grows, as lifetime incomes grow, as health levels improve, and as the baby-boom generation ages toward the primary ages of disease-related death, the economic reward to improvements in health will continue to increase.”

This suggests that medical research is vastly underfunded. Currently the United States invests about $40 billion annually in medical research. But the value of the lives extended by reducing the annual death rate from either of the leading killers, heart disease or cancer, by one-tenth of a percent would add up to nearly $50 billion.

So—increased risk taking aside—biomedical research is worth every penny, health care extends life, friendship and social support and collegial communities bring comfort and safety and stability, education enhances existence. Yet the people who most need these things get the least. What should we do? When Richard Epstein organizes a conference, the lawyers get the last word. And when Epstein speaks the message is, by and large, hands off.

There is an inherent tension, Epstein said, like fire and ice, between regulation and freedom, and from his experience with regulation he holds with those who favor freedom. Regulation is the realm of lawyers, and “when push comes to shove lawyers are the most powerful and the most dangerous” people on earth. He traced the history of public-health legislation from its early days, when it sought only to contain communicable diseases and ensure proper sanitation, to the emergence of a more inclusive, modern version—dominant after 1937—that covers “any and all matters that relate to the distribution of health care and health-care services.”

Such broad and meddlesome definitions of public health “will in all likelihood be conducive to the ill-health of the very individual it seeks to protect,” Epstein argued, citing several examples of regulatory failure (cases that protected the powerful and hurt the vulnerable, such as a quarantine affecting a specific ethnic group, or mandatory vaccination—with the option for the wealthy of buying their way out, thus posing a risk to others) traceable to equal parts venality and incompetence. Legislatures, he said, have “every incentive to get it wrong, and they will succeed.”

Wake Forest law professor Mark Hall offered his own example of government overzealousness. When his “germophobic” 14-year-old daughter was nipped by her new puppy she felt anxious enough to phone their veterinarian and ask about rabies. Although the dog had already received his shots, the vet was legally obliged to notify the local health department, setting in motion a process that culminated in a playful and perfectly healthy puppy being quarantined for three months.

Hall was troubled by the notion of siccing that same process on obesity, for example, by classifying overeating as a public-health problem. Once you identify a cause, such as cheap and tasty fast food, he said, then action becomes necessary. “Public-health law confers tremendous authority on government officials,” Hall said, “allowing measures that are justified only in situations of extreme emergency.” That makes sense in the battle against a pathogen like cholera or rabies, or even against a harmful behavior like smoking perhaps, but not for an “ecological problem” such as obesity, which is immersed in social, economic, cultural, and political considerations. At least one member of Congress has already begun to discuss launching a war on fat, said Hall, a new battle of the bulge. This is not “a rhetoric of prudence, balance, and restraint.”

So far the legal community agrees but has left room to change its mind. In January a judge dismissed a potential class-action suit blaming the McDonald’s Corporation for obesity in teenagers. The decision to dismiss was guided by the principle that “legal consequences should not attach to the consumption of hamburgers” unless consumers are unaware of the dangers of eating such food. If a person knows that eating copious orders of supersized McDonald’s products is unhealthy and may result in weight gain, “it’s not the place of the law to protect them from their own excesses.”

The real challenge confronting any attempt—whether legal, educational, or biomedical—to alter the social gradient of health was perhaps best summarized nearly 50 years ago by socialite Babe Paley, who was born rich, grew up thin, and married two rich, thin men. “You can’t be too rich,” she supposedly said, “or too thin.” Paley’s key insight was to connect the two. Marmot’s pioneering Whitehall study, for instance, showed the correlation between socioeconomic status and lifespan, but it also revealed that low status was associated with obesity, smoking, less leisure-time physical activity, higher blood pressure, shorter height, and coronary heart disease.

A glance at the conference speakers and taller-and-thinner-than-average audience revealed many of the same connections. While not exactly rich by Paley’s standards, they all had advanced degrees from elite institutions and the enhanced career paths that follow. Most had a BMI within spitting distance of 25. No one deserted the lectures to smoke. Most, if not all, reside in neighborhoods of high, even obsessive, collective efficacy, primarily Hyde Park, and all were deeply concerned about matters of public health. They were uniformly numbered among the “them that’s got,” and they were go-getters.

They apparently have the added advantage of being persuasive. Three months after the Chicago conference the president of the American Association for the Advancement of Science opened that organization’s annual meeting in Denver with a plea for more socially focused research, specifically citing Marmot’s Whitehall Studies. Floyd Bloom, chair of neuropharmacology at the Scripps Research Institute and former editor-in-chief of Science, author of more than 600 papers and the text The Biochemical Basis of Neuropharmacology—in short as hard-core a molecular biologist as they come—kicked off the meeting by telling his audience that genomic-based health care, though often described as a miracle on the horizon, is likely to be expensive and require many more years of research before new options are available to patients. “The puzzles of better health promotion and disease prevention may be approached more rapidly and effectively through intensified social-science research,” he concluded, “rather than by awaiting the expected evolution of gene-based explanations and interventions based on future genetic discoveries.” No longer a new kid on the block, the social-determinants field has finally been blessed and is coming into its own.


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