Month: June 2013

This is a few months old, but I can't always stay on top of the latest from monthly magazines in Australia. An Aussie doctor and writer offers a frank, sensitive, and comprehensive take on increasing rates of obesity and why we shouldn't expect doctors to fix it. It's long, but please read it before venting.
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By classifying obesity as a disease that implies that there are things doctors can do to cure or treat it.
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However, the doctors' tools are quite limited:

A recent New England Journal of Medicine article dealing with the rise of chronic lifestyle-driven diseases calls for a change in the way physicians think about their patients. The author suggests that medical students should be taught to be less reductionist, to learn how psychological, social and economic factors all act as determinants of disease. I do not know what medical school is like in the US, but even our surgeons – the most hard-arsed of doctors – sit reeling before the tragic combinations of circumstance and choice that lead our patients to weigh two or three (or four or five) times what they should. The doctors I work with have an excellent grasp of the bio-psycho-social factors that contribute to our patients' states, but we are only doctors. All we have are the tools of our trade: our ears, our voices, our hands, our pills and our scalpels. The waiting rooms are full, the waiting lists are long, the demand is swelling. Obesity is in many ways the logical endpoint of the way we live. Prevention beats palliation, but we'd need psychologists, motivational speakers, social workers, dieticians and physiotherapists to work with us in order to have any hope of tackling the problem. We’d need policy makers and activists. All we have are doctors like me.

In the absence of a holistic, comprehensive approach, we have doctors telling patients what they already know ("You should lose some weight!") and making them feel shittier than they already do. What we run up against, she suggests, is the reality that food has become a singular source of pleasure for a lot of people.

I ask a young 200-kilo patient what he snacks on. "Nothing," he says. I look him in the eye. Nothing? He nods. I ask him about his chronic skin infections, his diabetes. He tears up: "I eat hot chips and fried dim sims and drink three bottles of Coke every afternoon. The truth is I'm addicted to eating. I'm addicted." He punches his thigh….My patient is not addicted; he's a very lonely, unemployed young man who has gradually become socially isolated to the extent that the only thing available to him for comfort and entertainment is food. He has no friends, no money to buy other consumables, little education, no partner, no job. Some days he doesn't leave his bed. The choice for him is to eat this food or experience no pleasure.

And then, the kicker:

This is where the obesity-as-disease concept leads us – to a situation in which people demand that medicine shoulder the responsibility. What about the responsibility of the individual? And of society? My patient cries because the highlight of his day is returning from the supermarket with a plastic bag full of junk that he will eat and drink in his empty lounge room. What can I do for him? I can threaten him with his early demise, intensify his shame. I can offer him some evidence-based motivational lifestyle interventions – swap Coke for Diet Coke! Prescribe exercise? Walk for an hour at an average pace and you'll only burn off the equivalent of one slice of bread. I could take the old-fashioned approach and wire his jaw shut. I have no hope of resolving his loneliness, his hopelessness, his lack of a job. I could, and do, refer him to a psychologist – if he's lucky he may land one who is talented and sensitive and will try to get to the root of why this young man hates his own guts. More likely he'll be offered a few sessions of behavioural therapy that will make everyone except him feel better.

This hit me. I've been here.

I haven't been 200kg (440 lbs), but I've been through periods of my life in which eating was the sole thing I had to look forward to for days at a time. When you move to a new city, live alone, know no one, don't have many options for entertainment, and have some food/eating issues to begin with, it doesn't take very long at all for the pint of ice cream or the bag of Doritos or the candy bar to become the highlight of your day. It's the only thing that offers any pleasure. There's no one offering you a back rub before bed, no post-work happy hour with friends, no parties on the weekend, no frolicking outside on a sunny beach. There's food. There's work, dreary gray skies, frigid winters, and food. And that food is cheap – especially shitty food. If I want to do something I will get actual pleasure from, I can pay $75 for an hour massage or $2.99 for a bag of chips that will take me 45 minutes to eat. I can spend $400 on plane tickets and travel to visit friends somewhere, or I can spend $15 on pig-out food for Friday through Sunday.

That's the problem. That's why doctors can't help patients beyond giving them advice they've already heard, pills/surgery that won't work unless they change their eating habits.
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As the writer states, every "diet" that works amounts to the exact same thing: eat less, and stop eating so much garbage. We get it. The problem is actually doing it. We expect the doctors to "treat" the problem within an entire system set up to encourage it – a depressed and depressing economy, a trillion dollar fast food/snack/beverage industry and its refined marketing techniques, an agribusiness lobby that dominates the institutions of government, and a decreasing number of ways to connect meaningfully with the people around us.

Shockingly, doctors have yet to discover a pill that fixes all of that.

"Lisa, if you don't like your job, you don't strike. You just go in every day and do it really half-assed. That's the American way." – H. Simpson

Recently, a relative was telling me how disappointed she was in the school her kids (used to, but will no longer) attend. It seems that at this private Catholic K-8 the teachers threw in the towel with about a month to go in the school year.

The majority of May was filled with the kinds of things K-8 schools/teachers do when they want a day off – parties, Movie Days, assemblies, etc. The kids were having multiple "parties" per day to celebrate, well, anything the school could think of. The music teacher devoted two entire weeks to showing the students Toy Story…twice (??). In short, she told me that many parents were very upset, feeling that they had paid for nine months of classes and had barely gotten eight. Being a Catholic school, the tuition is not an inconsequential amount.

I sympathized. She told me tale after tale of things the school used to fill the days with anything but lesson plans and actual academic activities and her anger made sense to me. Not trying to stoke the fires or start a political debate, I just noted that this was not rare at any level of education, but was particularly common in private schools. Catholic schools are known for paying less than dick, so in this situation the kids are in the hands of teachers who haven't gotten a raise in 15 years and who were getting paid poorly to begin with. It doesn't surprise me, I pointed out, that in a situation like this people might go out of their way to do as little work as possible. When a job devalues employee, literally and figuratively, their response is often to work just hard enough to avoid getting fired.

The losers, of course, are the students. The parents are right to be angry, but I understand the mindset of the teachers. They are rational, and if the job isn't paying then they will seek to improve their lot by making the work easier. And nothing's easier than not teaching. I don't think she found this explanation persuasive, and I didn't push it. But it raises a larger question that I think about often: how hard do we have a right to "expect" people to work?

Even though many people can and do complain loudly about poor service, deep down I think we all understand that the kid at Taco Bell makes minimum wage, doesn't give a shit about the job, and isn't exactly going to go at 110% every single day. But how "hard" is a teacher supposed to work? Is he cheating you if he re-uses lesson plans rather than coming up with brand new and up-to-date ones every year?
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Is your doctor cheating you if she runs a test and diagnoses you rather than running all of the tests and spending hours reading about every possible thing that might cause your symptoms? Is your pilot lazy because he uses autopilot? Is your waitress lazy because she hasn't refilled your coffee as many times as you might prefer?

People are judgmental. Combine that with the fact that we pay for things (using the money that we have made our own sacrifices to obtain) and expect to be satisfied, and commenting on the work ethic of others is practically a national pastime. The previous thread on pensions noted that some people seem to think they invented the concept of hard work – nobody but me has even done an honest day's work! Some people certainly do have that attitude.

But often the complaints people make (as in the story retold above) are valid. The part I can't figure out is what to do about it. No employer is going to raise the salary of employees who clearly half-ass their jobs, yet if the compensation is low most people simply aren't going to work very hard.

From the teachers' perspective, what is the motivation to work 16 hours per day and move heaven and Earth to be the best teacher since Jaime Escalante if they get paid the same $31,000 per year for being…mediocre? Business schools have spent 30 years churning out people who believe in motivation by intimidation – work hard or else we will fire you, replace you, move to Mexico, and so on. And yes, an employer certainly has a right to expect employees to fulfill their obligations.
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This is where we see the large gap between fulfilling the requirements of a job – i.e., doing the bare minimum – and doing a good job. "Work hard and you will get promoted / get a raise" is the natural response, but in many of our workplaces I think we discover fairly quickly that the raises aren't coming no matter how hard we work (or they come, but with a truckload of additional burdens that vastly outweigh them).

That's the end result about all of this "Woe is us" from the owner and manager classes – we're constantly told that we can't be paid more ("We just can't afford it! We're barely breaking even!") but we're not expected to react strategically. The rational thing to do, if you know you can't profit from working harder, is to figure out the minimum amount of work you can do under the terms of your employment.

Of course, when certain people in our society do what is rational, it's "smart". When the rest of us respond rationally to incentives, we're lazy.

I owe my upbringing to the taxpayer.

Both of my parents owe essentially their entire lifetime of earnings to the taxpayer. With only brief exceptions, my mother has spent her entire working life as what used to be called a secretary for several different public school districts, and my father is entering his 30th year as, at various times, a prosecutor, elected official, and judge in a county in the southwest Chicago suburbs.

Accordingly, most of their friends are similarly employed.
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Some of dad's friends are people I have known (and vice-versa) since 1980, which is impressive since I didn't master the art of speaking until mid-1981. As these people have watched me grow from a baby to a 34 year old adult of considerable facial hair and minimal life accomplishments, I've watched them transition from young adults to…well, seniors on the verge of retirement.

Like most people who work for the government for their entire lives, their ability to retire relies on a public pension. Those pensions will provide them in most cases with something that approximates their working salary plus health care benefits. One of the great ironies in my mind as I began becoming politically aware was how much some of these people could bitch about taxes when every penny they earned and would continue to earn was someone else's tax dollar. And now that states are in austerity overdrive – Illinois being more strapped for cash than most – some of them are all aboard the "It's all the fault of the public unions and their goddamn retirement benefits."

As I became an adult (of sorts) I became bolder about questioning this sort of logic. And I came to believe, having had this conversation numerous times over the years, that the explanation is quite simple: individuals believe that they deserve the benefits they'll get (usually because they Worked Very Hard or Worked Their Whole Life for them) while the horde-like Others do not. And no matter what they do – double-dipping, etc. – they've earned what's coming to them. It's all those other people who haven't.

At a previous public university, I worked with a textbook public pension double-dipper. She "retired" at 52 having put in the 30 years of service necessary to draw her pension, then she continued to work in a different university position that would eventually give her a second pension (and currently gave her a state salary on top of the pension).
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Of course she was the office's resident Teabagger, and her laziness was such that I wondered if the EPA would re-classify her as some sort of lumber. And that's one of the most amazing things about being among those employed by the government – occasionally you run into these examples who scam the system in every way possible, do no actual work, and manage to piss and moan about taxes, the gub'mint, and the usual right-wing nonsense. Their pension(s) is different because they worked very hard for it, meaning they were physically present for the mandated amount of time on most days.

It turns out that double-dipping is for pussies, though, and triple-dipping is where it's at – at least according to John Cornyn. He's being paid his Senate salary in addition to three different State/county pensions totaling $66,000 annually from previous positions held in Texas. What's amazing is how much he receives for how briefly he worked – $6000 every year for the rest of his life for four years on a county court. $48,000/yr for six years on the State Supreme Court. And so on.

So, just to recap, a teacher or postal worker who puts in 30 years is greedy and entitled, but the John Cornyns of the world spends five fuckin' minutes on a county court and gets $6000 in the mail every year until death. I wish there was a more complex psychological explanation to offer here beyond simple hypocrisy and the belief – in the face of mountains of contradictory evidence – that "Everyone is lazy except me." Based on my experience throughout my career and indeed throughout my life, the excuses are rarely more complex than that.

Isn't it funny how new prisons open just after the factories and the public schools close? It must be that efficiency and responsiveness that the free market priesthood is always boasting about.

Isn't it funny how state governments and the Sacred Taxpayer balk at spending $5000 per public school student per year but don't balk at the $75,000+ per year that it costs to incarcerate one person? The free market encourages such forward-thinking investment.

The city of Philadelphia is closing 23 public schools to save money while breaking ground on a new $400 million jail and prison complex. Honestly, the reporting on this story has been disappointing. By focusing on the school closure-vs-jail opening dichotomy, it sets up the weakest possible argument. With falling enrollments (no doubt due in part to previous cycles of budget slashing) it is not hard to construct a logical argument for school closures. If these buildings are at 40% enrollment, it makes some sense for the school district to consolidate.

The real problem, which doesn't make nearly as sexy or ire-provoking of a headline, is what is happening to the schools that will remain open. The closed buildings are the least of Philadelphia students' and teachers' problems. The schools that remain open are now operating with budgets that have been cut to the bone.

Pink slips were recently sent to 19 percent of the school-based work force, including all 127 assistant principals, 646 teachers and more than 1,200 aides. Principals are contemplating opening in September with larger classes but no one to answer phones, keep order on the playground, coach sports, check out library books or send transcripts for seniors applying to college.

Ignore the buildings. This is the real issue. Remove everything that offers the remote possibility of keeping kids (especially in crappy neighborhoods) out of trouble – sports, clubs, music, art, etc. Then cut the staff to the point where teachers won't be able to pay attention to any individual student. Then continue to cut corporate tax rates, cry "budget deficit!", and start the cycle all over again.

So what's the overarching agenda here? Pushing people out of the city and into the suburbs? That doesn't exactly help the local tax base if the Philly school board chases residents away. Funneling more kids into charter and private schools? Conservatives have a hard-on for them, and the shittier they can make the public schools the better private/charter schools will seem by comparison. And for the students who can't afford / get into non-public schools and whose parents can't afford to move into the suburbs? Is the plan simply to use the remaining schools as hollow shells serving no purpose other than to house the children at state expense until they can be shifted to juvenile facilities, adult prison, public housing, and so on?

Yeah. Yeah, pretty much. That's the only possible outcome here when schools are stripped of everything except the light fixtures, one principal, and some teachers. We don't need a crystal ball to see how this is going to turn out.