More on the question of obesity

On The Independent On-line, via my Facebook feed a few days ago there was story of a young woman who is striking a blow against the body shamers and fat bashers. There are loads of these stories – personal responses to the vicious trolls who swarm the Internet in search of something to be offended, disgusted or enraged by.  

We all encounter the herds of inadequate people get pleasure out of venting their splenetic personalities on social media – slithering out from under their various rocks to rant and rail – and nothing brings out the haters like a fat woman who dares expose her body. 

Trolls exist because there are usually no consequences. They operate anonymously and/or at a distance and often they congregate with a crowd of other, like-minded, malicious inadequates. They're cowardly bullies and I have nothing but contempt for them. They need to be shamed; people need to stand up to them and to support the victims of bullying and bigotry. 

However, it's a very short-sighted person who argues that being significantly overweight does not involve an increased risk of developing major adverse health issues. 

When a woman's magazine runs a story about a comedian who happens to be significantly overweight and includes a shot of her in a bathing suit, it's not accidental.  Either she or the magazine wants to provoke a response.  I've no idea what the magazine's agenda was but Sofie Hagen describes herself as a "fat acceptance advocate", i.e. she sees obesity as a political issue and wants to ensure that fat people are treated equally and positively.  

Hagen rejects people who express concern about her weight – telling them to "fuck off" – which is fair enough when it's a troll hiding behind a faux concern about the health issues of obesity.  However, trolls are easily exposed, ask any of them to explain the physiology behind their concerns and they're at a loss. 

I can understand why Hagen and others like her are angry. I'm of an age where if I exposed my body in public the age-shamers would have a field day.  But, however vile and wrong the bullies are, it is a medical fact that obese people are at higher risk of developing diabetes, heart disease, liver cancer and musculoskeletal damage.  

Carrying large amounts of body fat – especially visceral fat – is a major health hazard with serious implications for affected individuals and for the medical and other services those people will inevitably have to draw on.  While Sofie Hagen may be relatively healthy at the moment, if she remains seriously overweight, chances are she will become steadily more unhealthy.  Most commonly, it's not a question of whether obese people develop health problems, but when, in what ways, and how badly. 

Hagen refers to the correlation between diet culture and capitalism, how the myth of thin equals beautiful has been sold to people by the beauty industry. This is true, but at the same time as the corporate world of fashion and pharmaceuticals exhorts people to be thin – the corporate world of processed and fast foods is busy making trillions of dollars out of making people fat.

if the tyranny of thin is a corporate construct, it now has a twin – the normalisation of fat. 

We need to be asking why we are seeing what seems to be a trend, in both mainstream and social media, to  try to normalise obesity.  I can understand why Sofie Hagen positions herself as a social activist and argues for an acceptance of fatness but, other than those who are suffering stigma and discrimination – who has a vested interest in trying to normalise what is widely acknowledged as a growing medical and social crisis? 

I suspect that lurking in the corporate shadows, PR companies are busily promoting the idea that being overweight – even extremely overweight – is normal and even desirable. 

PR companies routinely pump out fake news and biassed opinion to order.  Sometimes these are straight forward opinion or human interest pieces, and sometimes they're pseudo-science.

The international food industry knows it is facing a growing body of medical evidence that the food it produces is toxic. There is the potential of litigation which could make tobacco litigation pale into insignificance and, more immediately, the potential for massive loss of revenue flare numbers of people turn away from junk food. 

The facts are that obesity is a health crisis of almost incomprehensible proportions and it has spread beyond the borders of the USA – which started it all. 

If current trends continue, three out of every four Americans will be obese or overweight by 2020 and currently almost 4 in every 10 people are medically obese. In NZ one in three people is classified as medically obese, with the proportion in some demographics being far higher.  In the UK and Australia almost two out of three people are overweight or obese. Even the French are getting fatter, and in India and China obesity is growing.

In almost all countries the percentage of people who are overweight is increasing every year. Most worrying for the future is the massive increase in childhood and adolescent obesity with the growing incidence of type-2 diabetes in children.  

Activity is a factor certainly,  as is poverty. Things we don’t yet fully understand such as the effects, on plant and animal health, of climate change, soil depletion and pollutant levels may be factors, but the single biggest and most easily controlled factor is the ubiquity of simple SUGARS, and especially sweeteners derived from maize. 

The links between obesity and the availability of energy-dense, sugar-rich, low nutrient, processed and fast foods have been established and it’s only a matter of time before the giant corporations that have made trillions of dollars out of selling this toxic crap, will face the consequences.

In the meantime, I’ll continue to defend overweight people from vile bullies but I will not go along with the normalising of obesity. 

The Neo-Libs’ Charter

Neo-Liberalism as an ideology is short-termist, short-sighted and it has the effect of short-circuiting the social contract.

Neo-Liberal austerity measures and state asset sales, are a political choice – not an economic necessity.

Neo-Liberal application of monetarist economic theory has turbo-charged neo-colonialism. 

It has resulted in: profiteering, asset-stripping, unaccountability, steadily increasing prices for increasingly poor quality services and commodities, driving down of wages at the base while grossly inflating remuneration at the top, removal of job security, massive increase in personal debt, privatisation of profits and socialisation of costs, incalculable damage to the environment, and the use of technological advances to enable global finance capitalism while diverting vast swathes of people into a netherworld of misinformation, froth and nonsense.

The Neo-Libs’ Charter :

Reduce and privatise as much of the state as possible without compromising its coercive machinery, e.g., militarise the police to be ready to control internal dissent and maintain the military to be ready to control challenges to global capital deployment.

Allow and enable capital to roam freely across the globe in search of greater profits through the manipulation of financial markets, employment of cheap labour, investing in countries with "industry-friendly" health and safety and environmental laws.

Create a global dependence on the finance sector.

Massively reward the already rich.

Create social, political and economic buffer zones of affluent demi-elites with a vested interest in maintaining the economic status quo.

Demonise and undermine working class collectives.

Push down wages and conditions at the base.

Reduce employment costs by shifting them onto self-employed contractors.

Remove job security for most of the workforce.

Increase personal debt through various forms of bank credit- especially home loans and credit cards.

Increase incarceration by putting more poor people in prison and imposing longer sentences.

Encourage the fragmentation of the political opposition.

Extend some formal rights to previously marginalised communities as long as they don’t challenge the economic status quo.

Control the mass media through the concentration of ownership.

Use social media to divert, divide and dominate via a mass of outright lies, misinformation and nonsense.

Create international and domestic pariahs and scapegoats to foment social division, fuel moral panics and justify coercive and interventionist strategies.

The Man At The Bus Stop

In October 2013, 47-year-old Neil Jones was hospitalised in Christchurch Public Hospital. He had severe alcohol-induced hepatitis – inflammation of the liver.

Three weeks later, gastroenterologist Dr Richard Gearry decided that, despite having severe jaundice, Jones' condition had stabilised and he was faking his symptoms in order to stay in hospital.  Gearry ordered Jones' discharge. Other staff expressed disquiet about this decision in light of how ill Jones was and the fact that he was homeless.

Jones was taken by hospital security to a bus stop near the hospital, and left there.  He was wearing hospital pyjamas because he had soiled his own clothes.  He lay on the ground at the bus stop for six hours, severely jaundiced, barely coherent and unable to walk.  

The hospital’s security staff were instructed to tell members of the public who expressed concern about Jones, that he was alright.  He was eventually brought back into the emergency department but was not reassessed or readmitted.

Instead, police were called to remove him from the waiting room and to issue a trespass order – i.e. order him not to return on pain of arrest. The police officers did not question this and delivered Jones to the City Mission who took him in, despite having serious concerns about how extremely ill he was. 

The Mission asked the police officers for an assurance that they would take Jones back to hospital if he deteriorated.  When Jones began vomiting blood, the police were called and after a 2 hour wait, the Mission phoned for an ambulance.  Jones was readmitted to hospital and he died there two days later.

Neil Jones had become an alcoholic after his partner's suicide in 2008, and at his worst was said to have been drinking 3 litres of vodka a day. How he managed to afford to buy that much is not known.

What is known is that he wanted to stop drinking but couldn't do it on his own, and there is a shortage of places for alcohol and drug rehabilitation in Christchurch because of government funding cuts.  When he tried to get onto a rehab programme in late August 2013 there was a long waiting list and he started drinking again. 

Because of his severe alcoholism, his family and his partner had taken out trespass orders against him, which had left him homeless.  He was in the grip of a powerful current of extreme adverse circumstances and was unable to extricate himself from it. He was drowning and he needed a life line. 

When he was first hospitalised, he had not eaten for three days and was severely constipated – to the extent that his breath "smelled faecal" according to nurses. 

During his stay he was often drowsy and could not follow instructions. On the day of his discharge Jones soiled himself. The conclusion was he was doing that deliberately in order to stay off the streets even though he was severely jaundiced and the fact that bladder dysfunction along with reduced GI motility and loss of sphincter control leading to constipation, diarrhoea and incontinence are all features of advanced liver disease. 

I don't know what tests were done on Jones or what treatments he received. What I do know is that when a person's liver is profoundly compromised, waste products that are normally filtered out by the liver build up in the blood stream and can cross the blood-brain barrier resulting in one of liver failure's most horrible complications – hepatic encephalopathy.  

Hepatic encephalopathy can cause intellectual impairment, confusion, irritability, loss of control of bodily functions, drowsiness and ultimately, if untreated, it results in coma and death.  

The symptomatic treatment for it is the use of powerful laxatives to clean out the bowel and reduce the build up of neuro-toxins in the blood. These laxatives can cause explosive and uncontrollable diarrhoea.  

Another complication of advanced liver disease is variceal haemorrhage – which is what ultimately killed Neil Jones.  Cirrhosis – scarring of the liver caused by chronic inflammation – causes an Increase in pressure in the portal vein system which takes blood from the intestines to the liver. 

This portal hypertension results in enlarged and weakened veins in the oesophagus, stomach and rectum. As portal hypertension increases, these varices can rupture, causing internal bleeding, which will result in death if especially severe and/ or untreated.

The other major player in this end stage liver disease drama is hepatorenal syndrome. The kidneys can fail because of vasoconstriction as a consequence of the disturbances to systemic circulation caused by portal hypertension. 

The only way kidney function can be protected long-term is with a liver transplant or if the patient has sufficient healthy liver cells and can be kept haemodynamically stable until the liver is able to regenerate enough for systemic circulation to improve. 

However, the reality is that if portal hypertension is severe enough to cause varices and ascites (fluid leaking from blood vessels and liver which builds up in the abdominal cavity) the disease has already progressed to the point where a liver transplant is the only hope.

Liver transplants are hugely expensive and there are too few organ donors; the only hospital which performs them is in Auckland. To get onto the list you have to be judged to be a suitable candidate physically and psychologically, you must be able to be at the hospital within a few hours of a liver becoming available, have a person who can accompany you, and be able to live near the hospital until all the postoperative care is completed, which may take weeks.

That means if you are an alcoholic, if you are homeless, poor or you are judged for some other reason not to be a suitable candidate for transplantation, you will die. In fact, most people with advanced liver disease die.  Once active treatment ceases, they are sent home to die or they go into a hospice.  

For a man with advanced liver disease to be dumped at a bus stop in hospital pyjamas is so unthinkable it is hard to write about it without anger taking over. 

It has plunged me back into the storm of emotions I felt when I watched my younger brother die from liver disease with all of its many awful complications – refractory ascites, oesophageal varices, hepatic encephalopathy and hepatorenal syndrome. He was not in the same situation as Neil Jones but, like Jones' family, we were left with many unresolved questions about his treatment, especially on discharge. 

Another factor in Jones' tragic story is the extent of the pain that he may have been experiencing.  Pain management for cirrhotic patients is hugely problematic in that opioids cause constipation which increases the likelihood of hepatic encephalopathy, and non-steroidal anti-inflammatories can cause renal failure and gastric bleeding.  The only drug judged to be safe is paracetamol but in overdose paracetamol is acutely hepatoxic and what constitutes an overdose for a cirrhotic patient is hard to measure so it is prescribed in such small doses it is next to useless as an analgesic for severe pain.

Neil Jones went into hospital already carrying the label of hopeless alcoholic, and it does seem he became a victim of that undercurrent of moralism which so often accompanies it.  In addition to being desperately ill, poor and homeless, he had no one to act as his advocate - i.e. no one the hospital staff were immediately answerable to.  

If he was suffering from mild to severe episodes of hepatic encephalopathy he was not able to speak for himself or to look after his own interests.  By repeatedly soiling himself and being extremely confused he may have been seen as a problem patient by some staff. According to Doctor Gearry, it was feed back from some staff which led to his decision to discharge Jones, even though other staff challenged both the medical wisdom and the humanity of that decision.

Arguably the most telling thing about this is the fact that, despite the discharge debacle, no post-mortem was carried out, and the on-duty coroner decided there was no need for an inquest.  If Neil Jones' family had not complained, we'd never have known how appallingly bad his treatment had been. 

As anyone will tell you who has lost loved ones – even loved ones who were as hard to help as someone like Neil Jones – the loss is that much harder to bear when you believe there were things that could and should have been done which might have altered the outcome.

If a veterinary clinic dumped a stray dog, suffering from a painful and incurable disease, out on to the street to die, there would be immediate and extreme outrage.  As his mother has said, that is precisely what was done to Neil Jones. 

The system casually spat Neil Jones out and in so doing, it failed him so profoundly it is hard to comprehend that such a thing could happen in New Zealand.

Will The Caged Birds Sing?

"It is said that no-one truly knows a nation until one has been inside its gaols. A nation should not be judged by how it treats its highest citizens, but its lowest."  

– Nelson Mandela

The French philosopher, Michel Foucault, in Discipline and Punish, wrote about the move away from the old public festivals of punishment towards a sanitised, industrialised form that is largely hidden from the public gaze. 

The old forms of punishment were public spectacles – intended to entertain as much as intimidate the populace. Only the favoured (mostly the aristocracy) were granted a quick, clean and relatively private death. 

The ancient public rituals of judicial punishment – burning, hanging, beheading, disembowelling, flogging – have been replaced by incarceration, with its persistent surveillance, separation, solitary confinement and rigid discipline.  

Prisons that were once used either to hold debtors or political opponents or to hold the accused and condemned until they were subjected to corporal or capital punishment – have become the punishment.

With the emergence of the prison as the preferred, and more "civilised", form of punishment, the methods of killing have also become "scientific" and medicalised in most states that still execute their citizens.

The guillotine was considered a humane death in contrast to the ways a feudal traitor would have met his end. In hanging, the length of rope and weight of prisoner are carefully calculated to ensure, if not the hoped-for Hangman's Fracture, at least a rapid asphyxiation.  In electrocution, a wet sponge is placed on the head of the prisoner to hopefully render them unconscious if, as often happens, the electric shock does not kill them instantly.  But, it is with the use of lethal injection that this attempt to sanitise judicial killing, is at its most obvious – to the extent that the process often becomes a macabre parody of a medical procedure.

The modern, clean, high-tech penitentiary is presented as a huge advance on the chaotic and bloody bedlam of what went before. The very term "penitentiary" came about because the institutions were intended to be rehabilitative. The criminal was incarcerated, confined and isolated in small, monastic-like cells within a larger building, not just to protect civil society, but in order that the evil-doer might reflect upon, and repent his sins.

The truth is that separation and isolation, the enforcement of a rigid discipline, the removal of autonomy, the lack of privacy, the imposition of who is socialised with and when – are all punishments that strike at the very heart of what it means to be human. 

We are profoundly social animals but we did not evolve in vast swarms. Isolation is unnatural and stressful for us but so too is over-crowding and enforced association.

Our social arrangements – when healthy – allow us to choose with whom and when to interact, and when to be alone. For most of our social evolution those arrangements were within communities in which kinship and communal ties, and the normal distribution of age and experience, moderated and controlled group and individual behaviour.

Most prisons dispense with all the things that help keep us social and balanced and therefore human. As such they are inhumane – intended not to rehabilitate or even just to contain, but to punish. The State exacts revenge on behalf of the actual victim of a crime.

In the recent era, it has gone far beyond that.

The "panopticon prison", in which the incarcerated cannot escape the gaze of their gaolers, may be seen as a reflection of the growth of a surveillance society in which the citizen cannot escape the gaze of the State.  Most of us are more surveilled today than we have ever been in our history as a species. 

 The prison's rigidly imposed and enforced daily regimen and the removal of any autonomy may be seen as a reflection of the loss of autonomy as a result of the imposition, onto private lives, of the priorities, timeframes and schedules of business.  Most of us (especially the poor) do not freely choose whether, when, where or how we work.

The modern state uses the prison to hide many of its social problems. It sweeps poverty, addiction, homelessness, low educational achievement and mental illness under a judicial carpet and locks it all away behind impenetrable walls.

It also removes from the body politic, a potent source of social unrest; alienated, angry young men who have been shut out of a world which dangles the promise of status and material rewards but denies most the means to reach them.

When a society fails to provide educational and training opportunities and to create meaningful work; when it labels the under-employed and unemployed as a "feral underclass"; when it creates mandatory and longer sentences for the sorts of crimes the poor are most likely to commit, it declares a whole stratum of people to be a social problem that can be solved – in part at least – by imprisoning many of them.  

As felons, people are disenfranchised; some remain so even after release. Ex-prisoners are less likely to get scarce jobs, which cements their marginalised status and means they are more likely to end up back in prison.  

This self-fuelling system has reached its nadir in the USA where the total number of men and women imprisoned in federal and state prisons is equivalent to almost half of the total population of NZ. Young black men in the USA are more likely to be imprisoned than to get a decent education. They are incarcerated at an average rate of over 5 times that of their fellow white Americans and, in some states, that rate goes up to twice that. 

Black women are twice as likely to be imprisoned than white women. There are more women in prison in California today than there were in the entire USA in the 1970s. Women in prison often find themselves trapped in an intersection of class, race and sex controlled by an arm of a state which has already proven itself incapable of managing that intersection in wider society. 

The number of prisons in the USA has exploded since the 1970s – a large majority of them were opened in the eighties and nineties.  What Angela Davis called the "prison-industrial complex" emerged at the start of the neoliberal era and it has proliferated and spread its tentacles all over the developed world.

The ethnic and the social class profile of the inmates of these modern prisons is evidence that the entire system is not only racist but is intended to control those people who have been hardest hit by the rapacious, globetrotting capital of the neoliberal era. 

It is no accident that in the same era in the USA and elsewhere, there has been a massive proliferation of corporations which provide private security services, an increased militarisation of the police, and an increase in the number and confidence of armed rightwing militias.

The entry onto the scene of private prisons in the USA is a return to the use of convict labour.  In private prisons there is an economic imperative to increase profits by cutting the cost of staffing and the maintenance of buildings and of prisoners, and by making money out of convict labour. 

In the antebellum era, convict labourers were almost all black men. The chain gang's links to the abolition of slavery were as obvious as the system was cruel and oppressive.  These days in the USA the captive, hyper-exploitable prison labour force is still disproportionately black. 

Mostly prisoners work in factories hidden from the public eye but reactionary extremists like Joe Arpaio publicly parade shackled inmates wearing chain-gang style uniforms – a public reminder of an era when black men convicted for minor crimes were subjected to conditions as bad or even worse than slavery – including being literally worked to death.

The likes of Arpaio remind us that however clean, clinical, medicalised and scientific the modern surveillance state's prisons appear to be, there's an older, brutal reality which is played out inside them. This brutal order is allowed and even encouraged as long as it doesn't turn on the keepers, and as long as its ugly truth doesn't seep too far beyond the prison walls. 

One of the greatest ironies is that the brutality is attributed, not to the nature of the institution, but to the pathological nature of its inmates.  The truth is not that inmates are all predisposed to behaving badly, but that the system places barriers to, and often prevents them from behaving well.  Furthermore, it is intended to do just that in no small part because prisoners who behave badly while inside and once released, serve to justify the existence both of the prisons and of other examples of the surveillance state. 

In all of this NZ is nowhere near as bad as America but that’s more a measure of the enormity of the USA's failures than it is of our successes. 

Our society creates and perpetuates the conditions in which some people are more likely to commit crimes, often because they have no real choice. 

We have differential standards for defining and responding to crimes that have been committed by the affluent and the elite, and crimes that have been committed by the poor and the marginalised.

We punish certain types of crime committed by certain types of people more harshly which is evidenced by the fact that we imprison poor and brown skinned people more often, and for longer than we do affluent or white people. 

Our incarceration rate of poor and brown skinned people, like the incidence of poverty-related child abuse, is a national disgrace and makes a mockery of New Zealand's claims to be the progressive, first world nation it likes to think it is. 

Māori are 14.6% of New Zealand's population and 51% of its prison population. At current incarceration rates, Māori will half fill the hugely expensive new prisons the National Government is committed to building.

This ugly reality and the pretence that we are a decent, egalitarian and just society creates massive cognitive dissonance. Many Kiwis deal with that by excluding those people from the "real" New Zealand; they label them as "feral", as undeserving, as pathological. Their existence is deemed to be an aberration, nothing to do with real Kiwis who are fundamentally egalitarian, hardworking, decent and just. 

We pat ourselves on the back for such things as being progressive towards the LGBT community, for  having partly closed the gender wage gap, for being the first country to give women the vote, for having a young woman and a Māori man in the running to become Prime Minister and Deputy PM.  

These are all very laudable things but frankly,  while we have families that are forced to live in cars, homeless people who die of cold on the streets, thousands of kids who live in poverty, an appalling rate of violence against women and children, high levels of horizontal violence and incarceration of men of colour at rates which match those of the most racist of American states – we have no right to be smug and self congratulatory.  

I will leave you with this thought: if Black and Hispanic Americans were incarcerated at the same rates as White Americans, the US prison population would drop by almost 40%.  

If Māori and Pacifica men were incarcerated at the same rate as White New Zealanders, we would not need 1800 new prison beds and we could be looking at better, more social and productive ways of spending 1 billion dollars.