Thursday, July 25, 2013
Culture, power and personal responsibility for health
Our culture, at least the movie-going part of it, seems to have embraced the adage: With great power comes great responsibility. Somehow, at the same time, it seems to have ignored the inevitable, underlying principle: Power and responsibility are conjoined. This, in turn, implies a corollary our culture also neglects routinely, if not universally: Before anyone can reasonably be expected to take responsibility, they must be suitably empowered.
After all, if great power brings great responsibility, then presumably modest power brings more modest responsibility. And, by extension, utter lack of power would bring, you guessed it, something very much like utter lack of responsibility.
There is something almost viscerally objectionable about the renunciation of responsibility. We just don't like it! But before you let your viscera coopt your view of this matter, let's consider how consistently we already do accept the notion that in the absence of power, there is no responsibility.
Newborns aren't responsible for anything, not even personal hygiene, because they have no power, no control, and none of the relevant skills. Newborn babies can't take care of themselves, and aren't expected to do so. As children grow, they are expected to take on responsibilities little by little, as they acquire the skills to do so. Let's be clear about the sequence: Power comes first, responsibility after. Only after potty-training do we expect our kids to take on responsibility for this most basic need, and even then, we anticipate accidents early on. There is the basic power associated with any given ability, but then only practice makes perfect.
We can't, and don't, ask someone to be responsible for acting on some set of instructions they don't have the literacy to read. We don't ask 3-year-olds to follow written guidelines. We don't ask the average literate American to take responsibility for instructions written in Armenian. In the absence of power, responsibility is a non-starter.
We can't, and don't, expect someone to ride a bike they haven't been taught to ride. And we can't, and don't, expect someone who knows how to ride a bike to ride a bike, unless they have a bike! There are many ways to be disempowered. Among them are a lack of aptitude, and a lack of relevant resources.
There is, as I have noted before in a series to which I return now after a pause of several months, a prevailing tendency in our society to associate obesity and the illnesses attached to it to some deficit of personal responsibility. This could be true, but only if the requisite empowerment prevailed, and were being squandered. If the actual problem is a lack of power, then invoking a lack of responsibility implicates the wrong suspect altogether. This matters, because one is unlikely to fix what is broken while focusing on what isn't.
There is, to my knowledge, no scientific evidence that the current cohort of Homo sapiens is less endowed with personal responsibility than all prior cohorts. I've looked. If the evidence is out there, I can't find it.
Perhaps, nonetheless, your convictions cause you to believe that we are now less personally responsible than our forebears, even in the absence of evidence. Perhaps you feel compelled to believe that obesity must be about personal responsibility. But obesity is now hyperendemic not only among adults, but also children under 10. Are we truly inclined to believe that the average 6-year-old today is less personally responsible than all 6-year-olds through history? If not, but today's 6-year-old is apt be fatter, then something else is going on.
I think we know what it is, and it's all about power, and culture. Culture is a powerful influence on us all. When personal responsibility involves defiance of the prevailing forces of one's culture, it becomes a very tall order indeed.
Unfortunately, that is just the order associated with personal responsibility for health. Obesity and chronic disease are not just prevalent in the modern world, they are so prevalent as to constitute the new normal. To remain free of them is to be ... abnormal. Abnormal, for good or for ill, is always hard.
In a commentary published in The Lancet in February of this year, a group of scholars made the very point that the power of culture, and profit, is all too often oriented in opposition to health rather than in support of it. We might ask people to take responsibility in spite of it all, but that's a bit like pitching someone off our boat and assigning them responsibility for keeping afloat, whether or not they've ever learned how to swim. Relevant power is prerequisite to responsibility.
If you know it's important to control your weight and attend to your health, but almost everything in your environment and your culture conspires against such efforts, how responsible are you, personally? If as a child you get brief, tepid messages about eating well in school, but are then bombarded with state-of-the-art advertisements on screen and online encouraging you to do otherwise, are you truly personally irresponsible if you go with the prevailing flow?
If there is logic and value in such musings, I believe they all distill down to this: How can the whole of our collective responsibility for health be so much less than the sum of what we expect from its parts? Do we truly expect every individual, adult and child alike, to compensate with personal responsibility for the collective abdications at the level of culture, and corporation?
In his famous song of that very name, John Mayer laments that we keep on "waitin' on the world to change." But since the world changes slowly, and health can fall apart a whole lot faster, none of us can afford just to wait. We can seek out the skills we need to become empowered, and then express our personal responsibility. We can, and for better or worse, we must.
But that's not a reason to accept the world as it is. The world can change, and since the modern world conspires against our health it should change. We can't change it alone, but we can change it together. And there is no reason to choose between defending the health of your own body, and being part of the body politic, working to make the world a healthier place for us all. Collectively, we can put health on a path of lesser resistance so no one of us needs to work quite so hard to get there from here.
Taking responsibility requires empowerment. But even when empowered, leaping tall buildings in a single bound is asking a bit much of the mortals among us. The power and responsibility for lowering that bar, reside with our culture. Power over culture, in turn, resides with us.
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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Suneel Dhand, MD, ACP Member
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