Monday, November 5, 2012
Sowing smaller government, reaping salmonella
For the entire span of my career in medicine and public health, the U.S. FDA has been under-funded to do the job everyone expects it to do. I have heard this from colleagues in the agency my entire career, and have heard it directly from no fewer than two former FDA commissioners, one of whom is a friend.
The agency is supposed to review every medication that comes through the developmental pipeline and make sure the good ones are promptly approved, and the bad ones just as reliably rejected. It's a big job, considering the scope of the modern pharmaceutical industry, and mistakes in either direction can cost lives, but we expect the FDA to do it.
We also expect the FDA to monitor and safeguard our food supply. They are not entirely alone in this endeavor, of course; they have allies in other government agencies, such as the USDA and the EPA. But let's stick with FDA, understanding that this is in part preferentially about the job the FDA does, and in part about government agencies for which FDA serves as a good illustration.
No one notices when food outbreaks don't happen, but nobody much cares for outbreaks of food-borne illness that do. When they occur, as they do with disconcerting regularity, there is at first a degree of worry, perhaps fear, and in the case of outbreaks that are really big and bad, maybe even some panic. There are foodborne pathogens, from salmonella, to E. coli 0157H7, to C. botulinum, and others, that can be, and at times are, deadly. Foodborne infections can kill us. They can kill someone we love.
We all know this, but we can't really run from it, not without foreswearing eating altogether. We have to eat, and so we take our chances. We count on the FDA to shift those chances in our favor.
And when they don't, when outbreaks happen, we tend, both individually and collectively, to segue from fear to outrage as the threat dies down. How could this have happened? Who's to blame?
We are to blame. Because, as noted, the FDA has never had the person-power required to inspect the food supply with the rigor required to forestall such outbreaks more reliably than they do. And nobody else steps in to pick up the slack.
We should note that inspections do happen, of course, and save many of us from the outbreaks they prevent. But there are too few inspectors, too few inspections, and too many of us eating too much food from all over the country and world. The malady is far bigger than the remedy, and so we reap exactly what we sow.
FDA funding is, of course, not the only reason for so many foodborne infections. The kinds of food we eat, and our processing of them, are also relevant here. But that's not today's topic. For more on that subject, I recommend to you Six Arguments for a Greener Diet by my friends at the Center for Science in the Public Interest.
For today, let's stick with the perennially under-funded, under-staffed FDA, and mull over those foodborne infections in the context of political strife, and frequent calls for "smaller" government.
"Smaller government" makes a swell sound bite, because it sounds like standing up against waste, inefficiency, and the quagmire of bureaucracy. But in the course of political harangues where sound bites prevail, details tend to be omitted, and it's often hard to tell exactly who is apt to get bitten.
Smaller government doesn't just mean containing bureaucracy run amok. Nor does it seem to mean cutting the size of Congress in half, or laying off Supreme Court judges, although I frankly think good arguments could be made for both of those. It means fewer police, fewer teachers and fewer firehouses. We all know that government does jobs no one else does, such as building and maintaining interstate highways and bridges. Smaller government means less of that.
It means a smaller corps of engineers to maintain levees, a smaller national guard to respond to crises in our communities. It means turning employed people who earn money and pay taxes into unemployed people who compound our economic woes. But I'll leave such minor concerns to the politicians, and stick to my day job. In my world of medicine and public health, it means more salmonella.
Government does jobs nobody else does. Food inspection is an example.
Now, consider the food inspector who is unemployed instead of doing her job because "smaller government or bust" is in fashion. She is out of work, and so her family is struggling. They are not spending money, and so the things they might have bought go unsold. If there are many like her, and there are, companies take a hit. The economy languishes. You get the idea.
But never mind her, let's worry about the inspectors left on the job, and their need to do twice as much in too little time. And then, let's worry about ourselves!
That unemployed inspector is not on the job, so contaminated food at some farm or factory goes uninspected. Salmonella breezes by on a conveyor belt, unobserved, and finds its way into some product you take home to your family, or I to mine. We get sick, we writhe and suffer, we miss work. We incur medical bills. Maybe we get better, maybe not. Either way, it's a bad time, and a bad deal for all concerned.
Nobody likes waste, inefficiency, or bureaucracy. Nobody likes earmark boondoggles or pork-barrel politics. And I suspect all reasonable people would agree that government should be no bigger than it needs to be to do what it needs to do. Honestly, you can believe in a social safety net AND not like to see your tax money wasted on basket-weaving. But those of us in public health know that government hires real people to do real jobs, and often jobs nobody else will do if government doesn't do them. Like safeguarding our food supply.
So here's to ever smaller government, which sounds really terrific, until it's you, or someone you love, who winds up with salmonella.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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