Julie Guthman on health care

In a chapter of Weighing In titled “Whose problem is obesity?” Julie Guthman objects to the idea that “the costs of dealing with obesity are substantial and that the broader public pays for obesity because medical costs are pooled, so that the healthy pay for the unhealthy.” She writes,

So engrained are these ideas that Michael Pollan has chimed in on this too, with an editorial in the New York Times in which he used the platform of rising health care costs to link obesity and type 2 diabetes to “big food.” Remarkably the piece was expressing skepticism of Obama’s early proposal for health care reform because it focused too much on regulating the insurance industry and not on diet. As Pollan put it,

to listen to President Obama’s speech on Wednesday night, or to just about anyone else in the health care debate, you would think that the biggest problem with health care in America is the system itself–perverse incentives, inefficiencies, unnecessary tests and procedures, lack of competition, and greed….No one disputes that the $2.3 trillion we devote to the health care industry is often spent unwisely, but the fact that the United States spends twice as much per person as most European countries on health care can be substantially explained…by our being fatter.

This came not too long after Pollan defended the natural food supermarket Whole Foods against a proposed boycott. The boycott was initiated in response to the Wall Street Journal editorial by Whole Foods’ CEO, John Mackey, in which he attacked the “public option” under the supposition that “health care is not a right.” On the blog spot New Majority, Pollan wrote that “Mackey is wrong on health care, but Whole Foods is often right about food, and their support for the farmers matters more to me than the political views of their founder.” (49)

To understand this criticism, some context may be helpful. Guthman explains that this notion that obesity presents a sort of free-rider problem is rooted in an ideology called healthism. This term, she explains, “was first coined by the sociologist Robert Crawford in 1980 to ‘describe a striking moralization of health among middle-class Americans,’ so that health became a ‘super value’ that trumps other social concerns.'” In the United Kingdom, this ideology inspired government programs to educate people to make healthier choices, but its consequences have been more problematic in the United States:

In the United States…healthism helped legitimize a much more serious decommitment to state-mandated health services, taking the form of the “managed care” system, which, among other things, can exclude from care those with preexisting conditions, including obesity. The logic of managed care, as has now become evident, is to avoid unprofitable patients and/or shift costs back to patients, and thus to provide health care mainly to the healthy and wealthy, belying the idea that the public pays for obesity.

In any case, seeing care for certain groups as an excessive cost reflects an arguably perverse way of thinking about health care in terms of human need. You can see the moral hazard when you apply the same logic to education–for example, arguing that slow learners are a burden to the education system. It also neglects the role that the health care system plays in economy stability. The health care system provides an enormous number of jobs, particularly in labor-intensive primary care. In other words, care for the sick is an economic burden only in health care systems where profit is the bottom line and public services are underfunded and politically unsupported–that is, systems in which only market logic is considered legitimate. Nevertheless, the internalization of this logic helps explain the broad acceptance of the idea that obesity is the biggest economic health problem facing the United States. (54)

Thus, Guthman sees Pollan’s stances on health care as problematic because they play into this idea that health should be largely a matter of personal responsibility. By justifying a shoulder shrug at John Mackey’s opposition to public health care with the assertion that “Whole Foods is often right about food,” Pollan seems to subscribe to the idea that the problem of health care can be largely solved by individual agency. To Guthman, this reasoning is problematic in large part because it is blind to issues of social justice. I’ll write more about Guthman’s arguments about social justice in a subsequent post.



  1. You note that healthism led to government-sponsored food education in the UK, whereas it led to a “decommitment to state-mandated health services” in the US. I wonder to what extent this is a product of America’s traditional emphasis on individualism. Perhaps the problem isn’t the moralization of health per se but, rather, the US’s approach to moral problems. This isn’t a defense of healthism; I find the moral smugness of many health foodies repellent. But I should point out that excessive moralizing doesn’t make people indifferent to social justice unless they think that every moral problem is a strictly personal, as opposed to systemic, problem.

    • Adam Merberg said

      I agree with everything you say. Indeed, Guthman’s main problem with alternative food is that it fails to understand the problems politically. That said, she does offer a number of direct challenges to healthism (though I didn’t get to them here).

  2. Eric B. said

    I haven’t (and don’t think I want to) read Guthman’s book, but I have to question how Pollan could be called blind to issues of social justice. Pollan’s ways of eating are certainly elitist, but what he advocates and the local-organic food movement in general seem much more egalitarian and clearly concerned with issues of social justice. The local-organic food movement is full of young farmers making less than minimum wage by choice out of concern for ecological and social sustainability. How would Guthman suggest that we could show any greater concern for social justice?

    • Adam Merberg said

      I actually disagree that Pollan’s ways of eating are elitist. Privileged, for sure, but elitist is different. The way he talks to people is sometimes arguably elitist (in the sense that he’s a wealthy person telling the common people how to live their lives).

      As for Guthman’s point, it should be stressed that she isn’t against local and organic foods. Her point is that simply having these options isn’t enough to solve social justice problems because that approach will necessarily leave some people out. Here’s a quote that I think represents her view on the matter:

      The option to purchase alternative food affords relatively privileged people the opportunity to feel that they’re doing even more, to have their own consumption habits confused with philanthropy, even though, in practice pleasurable and ethical shopping can be contradictory (Johnston 2008). Insofar as eaters of alternative food are largely those who have been fortunate in the economy and with their bodies, they may even have a personal stake in upholding market alternatives rather than addressing structural inequality, which might lead to their losing wealth or income. In contrast to, say, paying higher taxes so that others may eat well through food assistance programs, participating in the pleasures of alternative food requires little sacrifice at all….But good eating cannot be conflated with ethical eating and effecting social justice; to suggest otherwise contributes to a sense of deserving that isn’t quite deserved.

      • Guthman is right: much of the time, alternative food is a way for rich people to feel like they’re helping society without having to get their hands dirty (e.g. without having to pay higher taxes). At the same time, we shouldn’t underestimate what a handful of comfortable suburbanites with yoga mats have accomplished through their buying habits: they’ve made “organic” a household term; they’ve created a market for environmentally-friendly foods; and they’ve expanded that market to the point where the federal government has drawn up standards for organic products. It may seem silly for foodies to obsess over organic produce when people are starving, but we have to face the fact that our current food system is damaging the environment. Foodies have introduced some important issues about food and the environment into the public discourse. Now we just need structural changes that will turn environmentally-sound food into more than just a niche market.

        Another point. We really need to beware of a sort of reverse-elitism here. Rich people’s values aren’t automatically less important than poor people’s values. The fact that poor people don’t eat organic food (since they can’t afford it) doesn’t mean that the environment is less important, in the long run, than fair wages and good working conditions. Rather, it means that systemic changes need to be made so that poor people can afford to consume in an environmentally responsible way.

      • Adam Merberg said

        Well said.

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