Blog | Friday, July 20, 2012

Public health and personal responsibilities

We are never alone. If you would, please hold that thought.

Politics, it seems, at least the variety practiced and prevailing in the U.S. nowadays, endeavors to make morons of us all. It gives us a contrived reality where there is no middle ground between the nanny who wants to tell us all what to have for breakfast, and the ninny who actually believes that big corporations won't exploit us in a world of no regulation or oversight. It implies to us that if ever we acknowledge the strength in unity, if ever we ask for, or offer, a hand up, we must be card-carrying members of the Karl Marx fan club. Anybody that concedes some value to the body politic is labeled a socialist.

What a load of festering rubbish! And as fate would have it, festering rubbish holds the key to our enlightenment on these muddled topics.

By and large, it's bacteria that cause rubbish, or anything, to fester. Sometimes it's other kinds of microorganisms, but let's not split cilia. Bacteria will do.

Bacteria, or their cousins, the archaea, were almost certainly the first life form on the planet. They are our distant ancestors. And, astonishing but true, they differ more from one another than all other forms of life differ from each other, or from them. Bacteria are the incubator of biodiversity on our planet. There is more fundamental genetic variation among varieties of bacteria than there is separating penguin from pine tree, orange from ocelot. I kid you not.

But I do digress. Let's get back to politics, or rather, the body politic. We are one, even when we're alone. We are, in fact, never alone.

Within our own skin, we are sufficiently in the minority to qualify as a potential rounding error. Bacteria outnumber our cells by 10 to 1 at least. The total population of the so-called microbiome totals roughly 90 trillion.

These germs, and although they are a vital part of us, they are, in fact, germs, contribute to a wide array of critical body functions. Their importance has turned them into New Age media stars as well, with coverage even A-list celebrities might envy. These bugs are big news.

Long known, though ever better studied, is the profound contribution of intestinal organisms to digestion. There is a growing body of evidence to suggest that disruptions to the normal flora of our GI tract may be implicated in a wide array of gastrointestinal disorders, and may be of particular importance in irritable bowel syndrome. There is a corresponding body of evidence, fast growing, that replenishing normal flora with probiotic supplements may confer benefit in such circumstances.

There is growing recognition that disruptions in gastrointestinal flora may be a factor, or in unusual but not truly rare cases of weight loss resistance, perhaps even the factor, conspiring to cause obesity. There is some early evidence that reconstituting healthy intestinal flora through the easy expediency of probiotic supplements, or the more dramatic and perhaps regrettably if aptly named "fecal transplant," may be quite helpful under such circumstances.

And there is growing awareness as well that our resident microbes influence almost every aspect of our physiology, from hormonal balance to metabolic rate to immune system function and inflammation.

I believe these bugs tell us more about ourselves than how inescapably germy we are.

In his characteristically articulate, compelling, and well-researched book, Outliers, Malcolm Gladwell builds a new podium for John Donne's time-honored admonition: "No man is an island." Gladwell demonstrates that the very examples of "self-made" people our society most reveres are in fact products of both aptitude and opportunity, circumstance and communal support. Neither triumph nor disaster is ever wholly owned by just one individual.

As with all of my ostensible sojourns into the tangents of philosophy, this one leads reliably back to my day job. The salient public health threats of our time are a wide array of social and environmental factors that in the aggregate contrive to make obesity, diabetes, and other chronic disease epidemic. Lifestyle factors that each of us potentially controls every day constitute the master levers of medical destiny, exerting greater influence on years in life and life in years than anything else. But these lifestyle factors are in turn much influenced by the modern environment in which we live, and which, collectively, we devised.

Against this backdrop, we have gravitated to the poles of ideology. Some invoke personal responsibility, as if lifting oneself up by the bootstraps is fully independent of all other influences, including, presumably, the existence of a boot-maker. Others argue for environmental reform as if we are entirely helpless while waiting on the world to change.

A middle path would concede that we like to be autonomous, and sometimes have the stuff to do so, but often don't, and are never entirely apart from the influence of others. An approach informed by biology would see an opportunity for common ground somewhere between "get there alone or die trying," and running a hammer and sickle up the flagpole.

In the case of nutrition, it is nonsense to pretend that parental or personal responsibility should suffice to overcome the clever and well-compensated efforts of people trained in marketing and advertising. But it is equally important to acknowledge that there are ways to confront the challenge of eating well in the modern world collaboratively, ways that don't require higher authorities telling us what to have for breakfast.

The human body is, quite simply, unviable without the biological body politic. With that as precedent and precautionary tale, perhaps society can acknowledge the same exigency, and accept that some challenges are best, or even only, addressed communally.

We would be in proud company to so concede. John Donne has told us so. Margaret Mead has told us so. Malcolm Gladwell has told us so. Hillary Clinton has told us so. Whoever said "in unity there is strength" told us so. And perhaps most irrefutably, Dr. Seuss has told us so.

I tell you so, as well, and these are the words I prefer: The best defense of the human body resides often with the body politic.

I am quite prepared to defend my autonomy. When I decide to ride my horse, or see The Avengers, or read Plato, I am deciding. I disavow any need to hold a referendum on the matter for my resident bacteria.

But maybe our inner reality can help us cool off the overcooked rhetoric on which our society seems so inclined to feed. Like it or not, we are all social, give or take the "ist," biologically. We are co-dependent on a whole population of other organisms. We cannot survive on our own, even within our own skins. I concede that without my resident microbes, I would die. Indeed, I concede that without them, I could never have lived.

Autonomy matters. Personal responsibility matters. We often can, and as often should, take matters of moment into our own hands. We often can, and as often should, be masters of our fate, and captains of our souls.

But we should nonetheless acknowledge that the best defenses of the human body reside largely, and often inextricably, with the body politic. Public health is for the public, and is best advanced by the collective efforts of the public.

In society, as in our own skin, from Gladwell's outliers of sociology to the gastrointestinal microbes of biology, we are never, ever alone.

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.