Malaria, "tropical medicine" and imperialism

Today is the 4th annual World Malaria Day, when we recommit ourselves to ending the mosquito-spread disease that infects half a billion people and kills a child every 45 second. But in order to achieve the goal of no malaria deaths by 2015, need to consider why parts of the world are still devastated by it. If we've know the basics of malaria transmission for a century but it remains a threat, then we must be ignoring factors critical to its survival. What follows is a brief history of "tropical medicine" and the changing context that shaped its theory and practice.

TROPICAL DISEASE or POVERTY DISEASE
     The prevailing medical orthodoxy reduces infectious disease to an abstract interaction between an individual and a micro-organism, without considering the socioeconomic conditions that constrain the individual or facilitate the infection. As a result treatment is reduced to medicine and lifestyle choices, without considering an individuals ability to access medicine or to make certain lifestyle choices. As a result of this reductionst approach, medicine regards malaria and other infections that plague the Global South as 'tropical diseases'. But in 1954 the director of the Calcutta school of tropical medicine offered a critical response published in the British Medical Journal:

"There are not many diseases peculiar only to tropical climates, although admittedly conditions in the Tropics are more favourable to their growth and spread.. Such devastating diseases as cholera, smallpox, plague, malaria, and leprosy that now prevail here were once very common in Western countries. If taken in the sense of latitudes, labels such as 'tropical disease' and 'tropical medicine' are largely misnomers; what is worse, they perpetuate a false idea that tropical countries, try as they may, are doomed always to suffer from these diseases. 'Tropical' diseases disappeared from the West mainly for three reasons: first, better and abundant food as a result of better cultivation at home and the importation of food from overseas; secondly, the removal of poverty as a result of the industrial revolution and the acquisition of colonies; and, thirdly, the institution of public-health measures, which led to better housing and hygiene, improved sewerage, and a safe water supply. If we consider 'tropical disease' in this light much of it is reduced almost to 'poverty disease'."

COLONIAL MEDICINE
     But colonialism imposed the exact opposite conditions on the Global South, fanning the flames of infectious disease. "Tropical medicine" emerged in the context of the scramble for colonies--when direct colonial control was an economic necessity--in an attempt to overcome this contradiction: how to bring the infectious diseases under control without altering the colonial conditions that spread them. As the British Medical Journal stated in 1897, "get rid of or avoid these germs and we get rid of a principle obstacle to the colonization of the tropics by Europeans."
     Two years later Britain established two schools of tropical medicine as joint ventures between the state and major companies. The owner of a Liverpool shipping line whose company shipped home loot form Africa became one of the main founders of the Liverpool school, and stated that "money spent in our school of tropical medicine is an investment, and we expect dividends from it." For US colonialism, a major source of funding for tropical medicine came from the United Fruit Company, whose profitable Latin American plantations required cheap and efficient labour. A century ago, when direct colonial control was an economic necessity for empires, companies and states joined forces to pillage the tropics, and the development of tropical medicine accompanied these projects.
     A simple glance at the pioneers in the field should raise suspicion as to the driving force of tropical medicine: malaria advances were made by Alfonse Laveran (a French army doctor in Algeria) and Ronald Ross (a British army doctor in India), advances in yellow fever were made by Jesse Lazear and Walter Reed (American army doctors in Cuba) and William Gorgas (an American army doctor in Panama). Despite their contributions to science, the implementation of tropical medicine was subordinate to colonial priorities. In Sierra Leone, the British used the the discovery of the malaria mosquito vector as rationale for imposing residential segregation, so the colonial officers could sleep at a safe distance from the infected local population.
     In Egypt, Britain discovered that the local poor population had high rates of schistosomiasis. Concern for the economic impact of a possible spread throughout the Empire precipitated a frenzy of medical research to discover how it was spread. But when the disease was found to be spread by sails in pollutd water, and therefore completely avoidable by the British military, research abruptly stopped. The disease and its victims were forgotten. As the leading investigator concluded, schistosomiasis "should not be treated as one of those diseases for which the individual is mainly, if not entirely, personally responsible."
     Whereas efficienty of foreign troops was the main goal of the British military base of Egypt, int he Belgian colonization of the Congo the focus was on labour efficiency. The Congo already had a low rate of trypanosomiasis. But the brutal conditions of colonization turned the disease into a raging epidemic at the start of the 20th century. In response, Belgium threw resources into finding a drug to keep the exploitted work force alive without dampening the proftable conditions of their exploitation.
     In the US conquest of the Philippines, sanitation measures were an excuse for repression. In 1902, after three years of crushing the local resistance, a cholera epidemic swept through the country, killing 200,000. The US launched a "cholera war", a supposed sanitation scheme that was suspiciously similar to the initial war and occupation: quarantines, house burnings, detention camps, and agricultural destruction. Of course this only fanned the flames of the disease.

MODERN IMPERIALISM and the DECLINE OF TROPICAL MEDICINE
     The "tropical diseases" that remain are proof that Western intervention has not led to development. Not only has global economic development not shifted to the global south, it has become more concentrated in advanced industrialized countries. As the British economist Chris Harman explained

"It is worth remembering why the European powers retreated from their colonies in the 1950s and 1960s after a century and more of carving up the rest of the world between them. They found it increasingly difficult and costly to hold on to them once modern national liberation movements came into existence and every grievance of any class translated itself into hatred of foreign occupation. At the same time, the economics of capitalism began shifting against the direct holding of colonies. The most important growth areas for markets and profitable investment were increasingly within the advanced countries themselves. Africa, the centre of inter-imperialist conflicts over the division of territory a century ago, today only accounts for around 0.6 percent of total direct foreign investment, and Latin America only around 6 percent."

World pharmaceutical market

     The pharmaceutical companies have mirrored this shift, with the entire continent of Africa now constituting only 1.3% of the global drug market. It is not surprising, following the logic of capitalism, that only 1% of new drugs in the past generation have been developed for "tropical diseases". Trypanosomiasis still kills 40,000 a year, a while life-saving treatment was an obsession for Belgian capitalism a hundred years ago, all production was stopped in 1999 because it was not profitable to save lives (it resumed production when it was discovered it could also be used in facial cream). As the former head of Merck stated, in sharp contrast to the Liverpool capitalist a century ago, "a corporation with stockholders can't start up a laboratory that will focus on Third World disease, because it will go broke. That's a social problem and industry shouldn't be expected to solve it."
     HIV/AIDS is the one 'tropical disease' that also affects people in the global north, though like all disease it spreads along lines of poverty and inequality and most people living with the infection are in the Global South. So while governments and pharmaceutical companies were pressured by AIDS activists to develop effective treatment, they have kept these technologies out of the hands of most people who need them.
     The shift in the global market away from the global south has been mirrored by a corresponding shift in dominant health care views. Once 'tropical disease' was reduced to a biological phenomenon, the solution for which was a 'magic bullet' that could cure the disease without disturbing the profitable conditions of colonialism. Now the dominant theory has become public health nihilism: dismissing medicine and preaching behavioural  and lifestyle changes--mosquito nets for malaria, circumcision for HIV--and economic development under tutelage from the West. Acknowledging that the majority of people in the global south cannot afford overpriced brand-name drugs, but wanting to gouge patients in the North, the dominant view now creates a false dichotomy of treatment for the rich and prevention for the poor. But as Paul Farmer, one the world's leading experts on HIV/AIDS, who has pioneered treatment in Haiti, explained in his book Infections and Inequalities:

"Too often, those who elevate the role of social determinants indict clinical technologies as failed strategies. But devaluing clinical intervention diverts attention from the essential goal that it be provided equitably to all those in need. Belittling the role of clinical care tends to unburden policy of the requirement to provide equitable access to such care."

CORPORATE GLOBALIZATION
     But "economic development" along neoliberal lines--with privatization, user fees and budget cuts--has undermined access to care, increased poverty, and exacerbated infections. An article in The Lancet described the impact of neoliberal policies for malaria in Nicaragua:

"I find it ironic that the Contra War was less a barrier to effective malaria control than the Structural Adjustment Program of the 1990s. Neglect for the rural poor has resulted in an epidemic greater than any since malaria eradication began in Nucaragua in 1947. User fees in this area generate few financial resources but sabotage the malaria control program and send the mistaken message that malaria control elective, rather than an essential service and national commitment."

     Meanwhile, structural adjustment in South Africa led to a cholera epidemic. As the World Bank explained, "work is still needed with political leaders to move away from the concept of free water for all." The result of forcibly depriving people of clean water was to drive them to polluted lakes and streams, leading to a cholera epidemic that killed 300 and infected 250,000. While pharmaceutical giants tried to prevent access to generic HIV/AIDS medication in 2001, they were defeated by a global movement led by South Africa's Treatment Action Campaign.

WAR and OCCUPATION
     Whereas most investment is within advanced industrialized countries, there is one commodity that continues to drive war and occupation outside the centres of the global market: oil. The Western-backed occupation of Palestine, in addition to direct attacks on the population, has also spread infections. According to a 2004 report of the International Journal of Health Services,

"The increasing rate of infectious disease in the occupied territories is influences by such factors as lack of sanitary water, overcrowded living conditions, poverty, improper sewage disposal, incomplete immunization, and malnutrition--all conditions that have been exacerbated during the current Intifada and are directly linked to Israel's policies"

     Meanwhile the West is presenting war as a new form of topical medicine,with aerial bombardment cloaked in the language of public health: crackers were dropped along with cluster bombs on Afghaninstan, Iraq was attacked with "surgical strikes", and depleted uranium is bringing "humanitarian intervention" to Libya. The supposed concern for international health obscures the fact that the cost of one B-2 bomber covers the total future spending on malaria research for the next 20 years, during which time the disease will kill 40 million people in Africa.
     But whereas tropical medicine a century ago attempted to contain infectious disease in order to promote the efficiency of foreign troops or local labour, war today spreads infectious disease in the conquest of oil and expansion of markets. A Pentagon report written before the Gulf War theorized that if water sanitation were destroyed in Iraq, "unless the water is purified with chlorine, epidemics of such diseases as cholera, heptatitis and typhoid could occur." This outlined in advance the Gulf War and UN sanctions regime, which deliberately destroyed civilian infrastructure and maintained a situation of malnutrition and disease that killed 1.5 million people.

ECONOMIC CRISIS, HEALTH CARE CRISIS
     While governments have thrown hundreds of billions of dollars at corporate bailouts and military expansion, they have underfunded the Global Fund for AIDS, TB and Malaria. While AIDS medicine can reduce transmission turn the infection into a chronic illness, it is denied to millions resulting in a reversal of life expectancy in some countries. Tuberculosis infections a third of humanity and remains a leading infectious cause of death 50 years after the discovery of curative therapy. Meanwhile malaria continues to kill while treatment is growing old: the leading anti-malarial medication was developed by the US military during the Vietnam War. These three infections highlight the devastating contradictions of 21st century capitalism: each year they kill 6 million human beings, not because we don't have the material capacity or advanced technology to overcome them, but because both are subordinated to profit.
     To roll back Malaria, we need to roll back the socioeconomic factors that contribute to it, and urgently divert resources from military and corporate bailouts to global health and poverty--combining access to medicine with improved living standards for all. As the Treatment Action Campaign said in 2004,

"The effect of the US government's unlawful war in Iraq has been to divert international attenption and resources away from global health and poverty. Hundreds of billions of dollars are being spent on the military instead of investing resources in the biggest threats to human security today: HIV/AIDS, tuberculosis, malaria, malnutrition and poverty."

Poem for Harper

Stephen Harper's story is he wants a majority

It’s boring me, does he really think that he needs more authority?

His priority is his minority of right-wing views

We lose, if we choose May 2 to endorse his priorities:

$30 billion dollar jets with engines excluded

And meanwhile military vets will get their pensions diluted

He has no sweats and no regrets for prison prices secluded

And don’t forget that his tax breaks had their benefits refuted

It’s a cahoot, he ignores a billion on summit “security”

And half a trillion more poured though the doors of the military

"Shut the fuck up" to women and cuts to human rights agencies

Austerity, it’s scaring me, this military-corporate Harpocrisy

Democracy? You’re kidding me, he’s in contempt of Parliament

He even had the gall to call it all the “Harper Government”

Prorogation and a manual on for committees to circumvent

Incessant malcontent, his only fan must be Margaret Wente

But seriously, how can this be, that he rules like the monarchy,

When a majority disagrees with his policies at home and overseas?

The secret is his harmony with Canada’s other corporate party

And the most absentee of MP’s, who never disagrees: Iggy

From the Tar Sands to EI to the war in Afghanistan

Ignatieff is so similar he’s like Harper’s right hand man

It’s a scam, he’s a fan of torture and would support war on Iran

Need I scan the clan of the man who claims he has a better plan?

From Chretien's 1990s cuts to corporate taxation

To Martin's 2004 coup which overthrew the Haitains

The Liberal Party policies push privatization

Environmental pollution and military occupation

Corporations are the basis of the unofficial coalition
Tuition rises while three times they joined to extend the mission
Not to mention both complicit in increasing emissions
Takes no magician to see how Harper rules without inhibition

But there, there, don’t despair, there’s another party out there, I swear

Beware the vote for the two millionaires who scare you with warfare

Instead, dare to vote for the one to which Medicare is heir

So on May 2 I’ll see you out there, with orange flair

Poem for Libya: Liberation through self-determination

The war on Libya’s a humanitarian disaster,

Depleted uranium fired by imperial masters.

Supposed salvation for the people of Benghazi,

While they murder Afghan, Palestinian and Iraqi.

How can it be, they ignore demands for medical supplies;

While Libyans die, the only help is bombing from the skies.

You can’t deny, we need asylum for refugees;

Instead they let them capsize and die in open seas.

Hypocriseas, it doesn’t take Hippocrates to see

The cure for Gaddafi is not those who sold arms to Tripoli.

Sarkosy bombs Libya while banning clothes for Muslim women;

Scapegoating them with islamophobic venom.

Don’t let him. And Obama’s bombs, a vehicle for AFRICOM:

Continuing 100 years of imperialism in Libya, it’s wrong.

Those who killed Omar Mukhtar don’t belong, have nothing to offer

But saving the profits of BP and SNC-Lavalin coffers.

Stephen Harper, joined the liberation of Libyan oil,

Using “Humanitarian intervention” to divide the spoils.

Makes my blood boil, the counter-revolution,

Those who armed Gaddafi—the source of persecution—are no solution.

Revolution of the Jasmine flower is what makes tyrants cower,

It wasn’t NATO that toppled Ben Ali and Mubarak, but labour power.

Now’s the hour, to continue liberation,

Bahrain, Yemen, Syria, which is the next nation?

Or perhaps Iraq, after 8 years of occupation,

Inspired by Tahrir is demanding liberation.

That’s the only salvation from this conflagration.

Real liberation comes through self-determination.

Beck, Ford and the limits of right-wing populism

10,000 protest Ford's austerity agenda

This has been a bad week for right-wing populists: falling ratings forced Glenn Beck to leave his Fox News program, while 10,000 marched against the neoliberal policies of Toronto's mayor Rob Ford. Both are major shifts from just a few months ago, when Beck dominated American television while Rob Ford won a landslide election. Many people saw these as evidence that the political views of the majority had lunged to the right. But Beck and Ford illustrate the contradiction of right-wing populism, and the possibilities for change. 

"LEFT" POLITICIANS AND THE ECONOMIC CRISIS

     The economic crisis of 2008 hit almost 10 years after the anti-globalization/anti-capitalist movement of 1999, and 5 years after the massive anti-war protests of 2003. For years majority opinion has been against war and growing numbers critical of neoliberal policies. But the response of politicians across the political spectrum has been to continue the same policies--escalating war, bailing out banks and corporations, cutting public services and attacking wages and pensions. 

     While the anti-war and progressive movements in the US helped elect Barack Obama to the presidency, he escalated war (continuing the occupation of Iraq, sending more troops to Afghanistan and launching drone attacks on Pakistan), continued the Patriot Act and Guantanamo Bay, and gave $700 billion of public funds to corporations while ordinary Americans continued to face home forclosure and unemployment. Meanwhile Toronto's left-wing mayor David Miller--who the labour and other progressive movements had helped elect in 2003--decided in 2009 to balance the books on city workers, blaming them for the recession and demanding concessions.

RIGHT-WING POPULISM FILLS THE VOID

     Glenn Beck, the Tea Party and Rob Ford are right-wing populists, whose appeal grows from people’s frustration with the economic crisis combined with the inability of the left in office to articulate a progressive response or support fightbacks when they emerge. As a result people's legitimate frustrations get deflected onto immigrants or unions instead of the corporations who created the crisis. Obama’s continuation of Bush policies undermined progressive movements that had elected him and opened up space for Glenn Beck and the Tea Party movement--which provide reactionary outlets for people's economic hardships, but fail to improve people's lives. As Gary Younge explained:

"When Tea Party supporters talk about 'taking our country back', they are – in part – expressing nostalgia. They literally want to take it backwards to a past when people had job security, and a couple on a middle-class wage could reasonably expect their children to have a better life than their own. The party they have been voting for and the candidates they are supporting now have actively and openly worked to undermine those aspirations. Their frustration at the Democrats' inability to deliver on their promises should be eclipsed only by their fear that the Republicans do manage to deliver on theirs. No wonder they are so angry. They keep treading on their own toes."

     Meanwhile the people of Toronto organized two massive movements against austerity--24,000 city workers on strike in June 2009, and 40,000 people marching against the G20 in June 2010--but the left in office turned their back on this mood, so right-wing populism filled the void. Despite having a “left” mayor in office during the 2009 strike, Toronto city workers ironically had less support from council than when they struck against right-winger Mel Lastman (when progressive councilor supported the strike), while council voted themselves a pay raise. Without a progressive response to this hypocrisy, Ford captured people’s anger with a right-wing response--attacking both workers and city council salaries. The silence of the left city councillors opened the floodgates for Ford’s right-wing backlash, which spilled over from city workers to transit workers, and now garbage collection and social housing.    

     Mass resistance against the G20 austerity measures and the $1 billion “security” enforcing it provided an opportunity for the left council to recover and reunite with progressives. But after the largest mass arrest in Canadian history, city council passed a unanimous motion to “commend the outstanding work” of the police. Facing no progressive response, Ford could carve out an even more reactionary position, arguing the police were too restrained in their brutality and that there should be no inquiry. 

BUILDING ALTERNATIVES

     But movements that challenge austerity are providing an alternative to right-wing populism. While Beck and the resources of Fox news marshalled less than 100,000 people to Washington in August 2010, left-wing comedians Stephen Colbert and John Stewart got double that number a few months later--showing the scale of people's frustration with right-wing divisive politics. Much more significant in terms of the grassroots groups and the issues they raised, was the "One Nation Working Together for Jobs and Justice" on October 2, 2010. Though ignored by the mainstream media, Democracy Now reported that

"More than 400 groups, including labor unions, as well as civil rights, gay rights, and environmental groups, endorsed the 'One Nation Working Together' rally. Organizers said the gathering drew a crowd of 175,000 people. The focus of the day was jobs, justice and education for all. The rally’s sponsors said they also hoped to demonstrate that they, not the tea party, represented the nation’s majority."

     The rally was a prelude for developments this year. If people took Glenn Beck and Fox News to represent American opinion they might think that Wisconsin governor Scott Walker could easily get away with union busting as part of a resurgent right-wing. But the explosive resistance in Wisconsin has provided a left-wing response to the crisis and inspired the nation. The April 4 Days of Action featured 1,200 events across the US in solidarity with Wisconsin workers for "the freedom to bargain, to vote, to afford a college education and justice for all workers, immigrant and native-born."

    Meanwhile Rob Ford is encountering growing resistance within months of taking office. On his inauguration on a cold December day, 150 people protested. On his first council meeting, a temper tantrum about "left-wing pinkos" by his invited guest Don Cherry sparked protest by councillors, while thousands of people across the city got "left-wing pinko" buttons that they continue to wear with pride. In March organizers of International Women's Day confronted Rob Ford about his cuts to public services, and that weekend thousands marched for public services and jobs. Shortly after it was revealed that Ford has given a cheat-sheet to his supportive councillors, instructing them how to vote. This is a sign of weakness. According to councillor Joe Mihevc,

"The Fords talk about running the place like a business but it’s been more like a military. My kids would call them control freaks. The risk is that people get tired of being told what to do. And I can tell you, there are a few who admit they’re having trouble sleeping at night. This isn’t what they were elected to do."

     While the mayor wants to build "Ford Nation" as a replica of the Tea Party, the labour movement can tip the balance in favour of progressive activism.  On April 9 unions joined with student and community groups to bring 10,000 people into the streets of Toronto, transforming Ford's motto "respect for taxpayers" into "respect for communities, public services and good jobs". Like the labour fightbacks in the 1930s--a few years after the 1929 Wallstreet crash--resistance to the Great Recession is a process, not an event. On January 29, 10,000 striking workers and their allies across the province marched against concessions by US Steel. While some on the left dismissed the mobilization, it built unity and confidence for workers to stand up against austerity, and along with the inspiration from Egypt and Wisconsin helped motivate people to protest April 9. This mobilization in turn has raised people's horizons to the mood for a fightback, providing confidence for local campaigns and giving momentum for the May 1 rally on Parliament hill, on the eve of the federal election, which will help challenge austerity from whichever government tries to impose it.

Fat phobia, the "obesity epidemic" and the medicalization of inequality

     Recently Toronto's progressive weekly newspaper, NOW, had a photoshopped front cover and feature pages showing rightwing mayor Rob Ford posing naked. This was clearly aimed at making fun of his weight, a recurring theme. When he announced he was running, NOW wrote about it in an article titled "fat chance", and during the election campaign right-wing rival George Smitherman suggested he "doesn't have the fitness for the rigour pace" (comments reinforced by media photos of his abdomen).  Last week while I was leafleting for the April 9 rally to protest Rob Ford's policies, one passerby grabbed a leaflet and called Ford a "fat fuck", a term reproduced on youtube clips and internet sites.

     There's plenty of reasons to criticize Rob Ford--from his racism and homophobia to his attacks on transit workers and public services--but his weight is not one of them. NOW defended itself on freedom of speech grounds, but that's besides the point. Free speech shouldn't pander to fat phobia or any other form of oppression. As one blogger noted,

"Ask yourself if NOW would ever do a Photoshopped cover of a female mayor in her underwear? The naked truth is that NOW would never have dared such a cover with Barbara Hall as mayor...Or if George Smitherman was the new mayor, can you imagine a cover with his worship wearing nothing but chaps and making fun of his sexual orientation?"

THE PSEUDOSCIENCE OF THE "OBESITY EPIDEMIC"

     One of the reasons fat phobia is so accepted is because it's become medicalized, giving it a veneer of legitimacy.  We're told that we live that we're gripped by an "obesity epidemic", which kills 300,000 Americans a year, a "threatening storm" that an article in the New England Journal of Medicine blames for a future decline in life expectancy. The policing of body size has entered daily medical practice with the "metabolic syndrome", a concept aimed at describing the inter-dependence of diabetes, high cholesterol and high blood pressure; to assess for this every family doctor is trained to measure their patient's blood pressure and lab tests...plus weight circumference. We're then supposed to council patients to "chose a healthy lifestyle" based on low-fat foods, on the notion that this will reduce obesity and its associated health problems. But this picture doesn't fit reality.

     Despite the focus on evidence-based medicine, much of the "obesity science" is arbitrary. Gerald Reaven, a leading scientist on insulin resistance, exposed the pseudoscience behind the metabolic syndrome, especially its inclusion of waist circumference:

"Not only are the cut points for the five chosen criteria arbitrary, there is no reason to believe that the individual elements of the metabolic syndrome are equally reflective of either the presumed basic defect or the risk of cardiovascular disease...although being overweight/obese increases the chances of an individual being significantly insulin resistant, by no means are all overweight/obese individuals insulin resistant, and, of greater clinical relevance, weight loss in overweight/obese individuals who are not insulin resistant does not lead to substantial clinical benefit."

 The site size-acceptance.org has also busted the "300,000 deaths a year" myth, noting that the authors of the quoted study objected to the misrepresentation of their findings, and that furthermore: 

"[the study] may have actually built upon the results of the 20 year long Cooper Institute Studies of 20,000 men which showed that fitness level and amount of exercise determined the morbidity risk rate regardless of what people weighed i.e. fat couch potatos and thin couch potatoes seemed at equal risk whereas fat exercisers seemed at no more risk than thin exercisers and at much less risk than thin couch potatoes."

     Not only does the supposed problem "fat = unhealthy" not stand up to scrutiny, but the supposed solution of lecturing people to "stop eating fat" doesn't reduce weight or the supposed obesity-related illnesses. The Women's Health Initiative followed 50,000 women for years, telling one group to eat a low-fat diet while the control group followed their usual diet. The results:  "Women assigned to this eating strategy did not appear to gain protection against breast cancer, colorectal cancer, or cardiovascular disease. And after eight years, their weights were generally the same as those of women following their usual diets." Despite the simplistic call for "good lifestyle choices", people can choose health in the same way that they can choose housing, income, working conditions, the food they eat, the air they breathe. In the market, people's ability to make choices depends on their socioeconomic condition.

 

 MASS OR CLASS?

     Last month, Scientific American published a study on the "diabetes belt" through the US:

the diabetes belt

"Going past national statistics, a new map shows more than 640 counties in mostly southern states had higher-than-average rates of diabetes, suggesting the need for more targeted prevention...the 644 counties in the diabetes belt match up to known risk factors for the disease, including: a high obesity rate, sedentary lifestyles, lower education levels, and more non-Hispanic blacks...The 15 states that have counties in the diabetes belt are Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia and West Virginia." 

the poverty belt

But there is a clear marker, almost universally ignored, that matches both diabetes and those "risk factors": poverty. These 15 states include 11 states with the highest poverty rates: Alabama, Arkansas, Georgia, Kentucky, Lousinana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and West Virginia. Fortunately not all the medical literature ignores poverty and income inequality. In another article in the New England Journal of Medicine--"Class, the ignored determinant of the nation's health", the authors reveal that:

"On the whole, people in lower classes die earlier than do people at higher socioeconomic levels, a pattern that holds true in a progressive fashion from the poorest to the richest... Unhealthy behavior and lifestyles alone do not explain the poor health of those in lower classes. Even when behavior is held as constant as possible, people of lower socioeconomic status are more likely to die prematurely."

     This is not to say that personal agency is not important. On the contrary: challenging the social and economic conditions that constrain choice is the best way to promote personal agency. Instead, many studies on obesity take these conditions for granted, controlling for differences in race and occupation—either explicitly, or implicitly by enrolling white middle-class people. This means filtering out the health impacts of racism and class, two of the most potent determinants of health. The premise is that these are natural and unchangeable, and should be eliminated from analysis, and that instead we should blame the difference in weight amongst ourselves. (For other good blogs on the obesity-shaming epidemic go visit here and here.) While this perspective is not medically useful, it serves economic and ideological purposes. 

BIG PROFITS

     The fear mongering about obesity can't be separated from the market that profits from it--from the multibillion dollar diet industry, to commercialization in general that thrives on reducing people's self-esteem so it can sell them a product. Meanwhile, the Canadian guidelines for the treatment of obesity were written by the president of Obesity Canada (an organization sponsored by food and drug companies) who owns stocks in Glaxo-Smith Klein and Eli Lilly, two pharmaceutical giants who happen to sell anti-obesity drugs. Like all free market industries, the pharmaceutical industry is made up of rival firms competing for market share. In the field of health this produces a pressure to pathologize (especially women). Obesity was turned into a "risk factor", and now its own disease, making fat phobia a very modern phenomenon.

MEDICAL SCAPEGOATS

phrenology

     But medicalized discrimination is far older. Far from being objective and neutral, medical ideology plays an important role in policing society, by pathologizing those who don't conform to narrowly-defined norms. Instead of focusing on economic conditions that collectively put us at risk of diabetes and heart disease, the obsession with obesity personifies these diseases, presenting them as the result of individual, lazy, and reckless behavior. The obsession with obesity recalls other instances in which groups of people have been labeled as “abnormal” or “at risk” because of their shape, origin, sexual orientation, gender identity, ability, and religion.

     The obsession with measuring people's waists in order pass to judgment on them is reminiscent of the early pseudoscience of phrenology, which measured people's heads as a basis of justifying social inequalities. Almost every oppressed group has at one time in history been blamed for an infection disease: First Nations blamed for TB, European Jews blamed for chlamydia, Mexican-Americans blamed for typhus, African-Americans and sex-trade workers blamed for syphilis, Haitians and gay men blamed for AIDS. Homosexuality was considered a psychiatric disease until the Gay Liberation Movement. Transgender people continue to fight against being pathologized. People with disabilities call for a broader definition of health instead of mainstream medicine's desire to “fix” them. Muslims are resisting attacks on civil liberties that use the language of “public safety” in order to restrict their rights to movement, attire, athletic competition, occupation, and voting.

"social hygiene" warning

     In all these situations the “target of intervention” has been the supposedly monolithic and deviant behaviours of oppressed groups rather than the social and economic conditions that place them, and others, at risk. The results have been social stigma or repressive laws, rather than accessible health care, better housing, and higher wages. In the 19th and 20th century when infectious disease dominated there was a "social hygiene movement" that provided medical justification for a moral crusade against deviant sexuality (everything from dancing to prostitution, along with homosexuality and inter-racial partnerships) but as the major medical problems for industrialized countries have shifted to diabetes, heart disease and cancer, the source of the blame has shifted from people's hygiene to their size. This ignores the real problems that threaten to undermine life expectancy: income inequality, lack of health care, unhealthy food driven by competition in the food industry to make things as cheaply as possible, and cuts to social services that deprive schools or community centres of fitness opportunities. (For a discussion of how biomedical reductionism affects our understanding of cancer, see my other posts here and here).

TOWARDS A HEALTHY WORLD

     The most important determinants of health are: 

1. Income and Income Distribution 2. Education 3. Unemployment and Job Security 4. Employment and Working Conditions 5. Early Childhood Development 6. Food Insecurity 7. Housing 8. Social Exclusion 9. Social Safety Network 10. Health Services 11. Aboriginal Status 12. Gender 13. Race 14. Disability

These are the issues on which to challenge Rob Ford; not his body but his policies that undermine the key social determinants of health. That's why thousands of people--representing a healthy diversity of bodies united in the demand for a better and healthier world for all--will be protesting this saturday. Fat phobia not welcome. 

Continue King's dream: support workers rights, stop the war

The April 4 demonstrations for economic justice and April 9 demonstrations against war offer the chance to continue Martin Luther King's legacy. As he declared on April 4, 1967, "Our only hope today lies in our ability to recapture the revolutionary spirit and go into a sometimes hostile world declaring eternal hostility to poverty, racism, and militarism."


KING'S DREAM
     Martin Luther King, killed 43 years ago today, is often reduced to a saintly figure, a simple dreamer who advocated civil rights divorced from all other causes. But King was part of a mass movement that combined ideas with action, organizing multiracial non-violent civil disobedience that overthrew Jim Crow in the South. Through the process he not only got arrested dozens of times, but began connecting civil rights with other issues. Even by the time of his famous "I have a dream" speech, civil rights leaders were looking beyond the legal rights that were being won and connecting the fight against racism with the fight for economic justice. As Bayard Rustin, one of King's mentors and the chief organizer of the historic 1963 March on Washington for Jobs and Freedom, described:

“integration in the fields of education, housing, transportation and public accommodation will be of limited extent and duration as long as fundamental economic inequality along racial lines persists. When a racial disparity in unemployment has been firmly established in the course of a century, the change-over to ‘equal opportunities’ does not wipe out the cumulative handicaps of the negro worker. The dynamic that has motivated negroes to withstand with courage and dignity the intimidation and violence they have endured in their own struggle against racism may now be the catalyst which mobilizes all workers behind demands for a broad and fundamental program of economic justice”. 

Or as King put it, "What good is having the right to sit at a lunch counter if you can't afford to buy a hamburger." He also went further. Against the advice of Rustin and other civil rights leaders, King began speaking out against the Vietnam War, connecting the war abroad to the war at home. As he said in his speech on April 4, 1967,

"We were taking the black young men who had been crippled by our society and sending them eight thousand miles away to guarantee liberties in Southeast Asia which they had not found in southwest Georgia and East Harlem. And so we have been repeatedly faced with the cruel irony of watching Negro and white boys on TV screens as they kill and die together for a nation that has been unable to seat them together in the same schools. And so we watch them in brutal solidarity burning the huts of a poor village, but we realize that they would hardly live on the same block in Chicago. I could not be silent in the face of such cruel manipulation of the poor."

     King also spoke out against the impact of the war on the people of Vietnam, in words that could be written for the people of Afghanistan today:

"We increased our troop commitments in support of governments which were singularly corrupt, inept, and without popular support. All the while the people read our leaflets and received the regular promises of peace and democracy and land reform. Now they languish under our bombs and consider us, not their fellow Vietnamese, the real enemy."

 The following year, as he planned his Poor People's Campaign to return to Washington demanding economic justice, King went to support 13000 Memphis sanitation workers on strike. It was here, on April 4, 1968, that he was assassinated. The following week the Memphis workers won union recognition and wage increases.

KEEP KING'S LEGACY ALIVE: APRIL 4, APRIL 9
     Today hostility to poverty, racism and militarism is heating up again. Revolutions in Tunisia and Egypt detonated revolts across the Middle East and North Africa, and helped inspire Wisconsin workers to stand up against union-busting. Now their struggle has inspired the nation: On April 4, 2011 there are more than 1,000 demonstrations across the US for economic justice, which Martin Luther King III says his father would support. As the organizers of "We Are One" write, 

"Join in solidarity with working people in Wisconsin, Ohio, Indiana and dozens of other states where well-funded, right-wing corporate politicians are trying to take away the rights Dr. King gave his life for: the freedom to bargain, to vote, to afford a college education and justice for all workers, immigrant and native-born. It’s a day to show movement. Teach-ins. Vigils. Faith events. A day to be creative, but clear: We are one."

     This weekend will be another chance to keep Martin Luther King's legacy alive: on April 9 there will be rallies across the US and Canada against war. While there are attacks on public sector workers and budget cuts for healthcare and education, billions are being wasted on the bloody war in Afghanistan, the Vietnam War of our time which has recently reached its My Lai moment. As Seymour Hersh wrote,

"In photographs released by the German weekly Der Spiegel, an American soldier is looking directly at the camera with a wide grin. His hand is on the body of an Afghan whom he and his fellow soldiers appear to have just killed, allegedly for sport...We saw photographs, too, at My Lai 4, where a few dozen American soldiers slaughtered at least five hundred South Vietnamese mothers, children, and old men and women in a long morning of unforgettable carnage more than four decades ago."

     Despite support for the war by US Democrats and Republicans, and Canadian Liberals and Conservatives, a growing majority of Americans and Canadians (including growing numbers of troops and military families) are against the war and want the troops home. As Obama starts his re-election campaign, and Canadian parties enter the midway point of their election campaign--with the NDP being the only party to call for an end to the war--April 9 is an important chance to display the majority opposition to the war and make it an election issue.

DREAMERS AWAKE

     Martin Luther King was part of a revolutionary wave that swept the globe: the year 1968 saw student protests and urban revolts from France to the US, uprisings from Czechoslovakia to Pakistan, and the Tet offensive that galvanized the national liberation movement in Vietnam--to name but a few. This year we've already seen mass demonstrations against austerity from London to Wisconsin, revolution in Tunisia and Egypt, and ongoing revolt across the Middle East and North Africa. By learning from King we can continue his legacy:

"These are revolutionary times. All over the globe men are revolting against old systems of exploitation and oppression, and out of the wounds of a frail world, new systems of justice and equality are being born. The shirtless and barefoot people of the land are rising up as never before. 'The people who sat in darkness have seen a great light.' We in the West must support these revolutions."