Single-Payer Health Care and Medical Innovation

This New York Times Economic Scene by Tyler Cowen argues against a single-payer health care system:

Poor U.S. Scores in Health Care Don’t Measure Nobels and Innovation By Tyler Cowen, Economic Scene, NY Times: Advocates of national health insurance cite an apparently devastating fact: the United States spends more of its gross domestic product on medical care than any nation in the world, yet Americans do not live longer than Western Europeans or Japanese. More Americans lack insurance coverage as well. It is no wonder that so many people demand reform.

But the American health care system may be performing better than it seems at first glance. When it comes to medical innovation, the United States is the world leader. In the last 10 years, for instance, 12 Nobel Prizes in medicine have gone to American-born scientists working in the United States, 3 have gone to foreign-born scientists working in the United States, and just 7 have gone to researchers outside the country.

[Of the] six most important medical innovations of the last 25 years, ... four innovations ... were developed in American hospitals or by American companies... Even when the initial research is done overseas, the American system leads in converting new ideas into workable commercial technologies. In real terms, spending on American biomedical research has doubled since 1994. By 2003, spending was up to $94.3 billion..., with 57 percent of that coming from private industry. The National Institutes of Health’s current annual research budget is $28 billion, All European Union governments, in contrast, spent $3.7 billion in 2000, and since that time, Europe has not narrowed the research and development gap. America spends more on research and development over all and on drugs in particular... From 1989 to 2002, four times as much money was invested in private biotechnology companies in America than in Europe.

Dr. Thomas Boehm of Jerini, a biomedical research company in Berlin, titled his article in The Journal of Medical Marketing in 2005 “How Can We Explain the American Dominance in Biomedical Research and Development?” Dr. Boehm argues that the research environment in the United States, compared with Europe, is wealthier, more competitive, more meritocratic and more tolerant of waste and chaos. He argues that these features lead to more medical discoveries. About 400,000 European researchers are living in the United States, usually for superior financial compensation and research facilities.

This innovation-rich environment stems from the money spent on American health care and also from the richer and more competitive American universities. The American government could use its size, or use the law, to bargain down health care prices, as many European governments have done. In the short run, this would save money but in the longer run it would cost lives.

Medical innovations improve health and life expectancy in all wealthy countries, not just in the United States. That is one reason American citizens do not live longer. ... The gains from medical innovations are high. For instance, increases in life expectancy resulting from better treatment of cardiovascular disease from 1970 to 1990 have been conservatively estimated as bringing benefits worth more than $500 billion a year. And that is just for the United States.

The American system also produces benefits that are hard to find in the numbers. ... Given that many Americans walk less and eat less healthy food than most Europeans, the longevity boost from health care in the United States may be real but swamped by the results of poor lifestyle choices. In the meantime, the extra money Americans spend to treat allergy symptoms, pain, depression and discomfort contributes to personal happiness.

Compared with Europe, the American system involves more tests, more procedures and more visits with specialists. Sick people receive more momentary comforts and also the sense that everything possible has been done. This feeling is of value to the family even when the patient does not improve. In contrast, European countries have not created comparably high expectations about the medical process...

American health care has many problems. Health insurance is linked too tightly to employment, and too many people cannot afford insurance. Insurance companies put too much energy into avoiding payments. Personal medical records are kept on paper rather than in accessible electronic fashion. Emergency rooms are not always well suited to serve as last-resort health care for the poor. Most fundamentally, the lack of good measures of health care quality makes it hard to identify and eliminate waste.

These problems should be addressed, but it would be hasty to conclude that the United States should move closer to European health care institutions. The American health care system, high expenditures and all, is driving innovation for the entire world.

First, the main argument is that switching to a single-payer system would stifle innovation. But I'm not convinced the case has been made that it is the difference in health care systems that has caused the agglomeration of research facilities in the U.S. Even if the U.S. were a single-payer system, drug companies, etc. would still do research and it is likely that much of it would be carried out in the U.S. just as it is now. In addition, as noted in the article, much of the research that is done here is funded directly or indirectly by the government. Second, given that European countries can free ride on this research, comparing the amount spent in the two countries may not accurately reflect European willingness to fund health care research since the two figures may not be independent. If the U.S. spent less, European countries might be induced to spend more. Third, Tyler says "The American government could use its size ... to bargain down health care prices... In the short run, this would save money but in the longer run it would cost lives." I understand less spending would cost lives, but I'm not sure I see why driving prices down toward marginal cost is necessarily inefficient from the free market perspective taken in the article, particularly if drug companies, etc. have market power. Fourth, the Veteran's Administration hospitals are far ahead of private sector hospitals in implementing information technology undermining the claim that private sector providers are more innovative. With 20 cents of every dollar insurance companies spend devoted to avoiding paying claims and with all the other waste and inefficiencies in the current system, but with only 2 cents needed for overhead in the VA system, the VA can use the reclaimed resources to improve health care rather than to avoid paying the bills. Finally, here's Paul Krugman on the need to control cost escalation arising from the pressures from the powerful "medical-industrial complex" to adopt increasingly expensive drug therapies and procedures:

[T]o get health reform right, we'll have to overcome wrongheaded ideas as well as powerful special interests. For decades we've been lectured on the evils of big government and the glories of the private sector. Yet health reform is a job for the public sector, which already pays most of the bills directly or indirectly and sooner or later will have to make key decisions about medical treatment. ...

Consider what happens when a new drug or other therapy becomes available. Let's assume that the new therapy is more effective ... than existing therapies ... but that the advantage isn't overwhelming. On the other hand, it's a lot more expensive than current treatments. Who decides whether patients receive the new therapy? We've traditionally relied on doctors to make such decisions. But the rise of medical technology ... makes ... medicine ... in which doctors call for every procedure that might be of medical benefit, increasingly expensive.

Moreover, the high-technology nature of modern medical spending has given rise to a powerful medical-industrial complex that seeks to influence doctors' decisions. ...[D]rug companies in particular spend more marketing their products to doctors than they do developing those products ... They wouldn't do that if doctors were immune to persuasion.

So if costs are to be controlled, someone has to act as a referee on doctors' medical decisions. During the 1990's it seemed, briefly, as if private H.M.O.'s could play that role. But then there was a public backlash. It turns out that even in America, with its faith in the free market, people don't trust for-profit corporations to make decisions about their health.

Despite the failure ... to control costs with H.M.O.'s, conservatives continue to believe that the magic of the private sector will provide the answer. ...

Comments

[bakho]

Where is the analysis of where these Nobel prizes are made? These Nobels are NOT going to MDs or people in the Medical Industry. Nobels are being awarded to academic research scientists working in basic research at universities. Some of the research was done decades ago.

Let's talk about the educational philosophy of Thomas Jefferson, or the Land Grant Act that provided for institutions of higher learning to advance the adoption of scientific agriculture and engineering. Note that this model is increasingly being applied to health care practices, business management, etc. This has little to do with who pays for health care.

The bottom line is that individuals pay for health care. We pay through taxes, or we pay through lower wages, or we pay the doctor direct, or we pay the insurance industry a profit to distribute the risk. Innovation is not connected to health care dollars.

[bakho]

There are a lot of health care innovations (the best ones) that actually cost less money.

[calmo]

Excellent post from bakho as usual, to which I shall try to respond to later.

I'm waiting for the message "Shucks folks, Americans don't lead a healthy lifestyle, so comparisons to our European counterparts are misleading and unfair. If the populations were interchanged leaving the medical apparatus in place, this would be obvious." (It's not just the Super-Size It, but the conditions that have cultivated this.)
But that doesn't happen because we need to deny that the War On ...and On, has unhealthy consequences. (The global war on terror is not distributed as evenly as some think.) [Don't forget Poland!]
No, instead we are distracted (ok, misled if you think there is an element of intention --you wanna see my little puppies in the back of my truck?) by this examination and catalog of US medical innovations.
At the risk of boring you to tears, I note that the distribution of these health services is again ignored: the wealthy's vs the poor's share, (liposuction vs preventative programs); the services are not equally distributed across the demographic profile; and the history of this American/European health.

[yartrebo]

Medical research and healthcare are (or at least should be) two different areas.

To do research, you train scientists and build labs. To give healthcare, you train doctors and build clinics and hospitals.

The two can be done very much independently of each other.

[JohnDewey]

vartrebo: "Medical research and healthcare are two different areas. To do research, you train scientists and build labs. To give healthcare, you train doctors and build clinics and hospitals."

Most research is probably done in labs. But development and testing of many, perhaps most, medical innovations is done by physicians in hospitals. My wife worked for several years with a couple of such physicians.

[spencer]

Tylor is clearly one of the best Liberaterian economist around.

But it seems to be there is an interesting trend emerging. Generally the liberaterians argue strongly
that all government interference is inefficient and a deadweight loss. But recently they have been arguing very strongly that the US mixed system
of providing health care is a great system.

Sure is a strange development, I wonder why they have become such great defenders of medicare, etc..

[calmo]

spencer (not generally recognized for his humor), are you gunning for us with those rats? [People, he must be deliberately turning spell check off...the gun does not load itself, not my gun anyhow.]
Tyler, spencer, Tyler is exhibiting symptoms of a tired mind. I know what I'm talkin about.

[anne]

Spencer:

"But it seems to be there is an interesting trend emerging. Generally the liberaterians argue strongly that all government interference is inefficient and a deadweight loss. But recently they have been arguing very strongly that the US mixed system of providing health care is a great system."

Nice. Research based medicine's strengths is quite other than the health care system's weakness that accounts for 47 million Americans with no insurance to begin with.

[Luiz]

"United States spends more of its gross domestic product on medical care than any nation in the world, yet Americans do not live longer than Western Europeans or Japanese"

The money is not being spent wisely. Excessive malpractice avoidance, with its prevention and insurance costs and, when it fails, the cost of legal procedures, certainly inflate costs.

[JohnDewey]

Spencer,

I think most libertarians would prefer a health care system composed of private enterprise and private charity. But I see no way to dismantle what we have today - with the dependence of so many on government healthcare.

I think most libertarians are, like me, scared to death that liberals might somehow get implemented the foolish concept of 100% socialized medecine. I sure as hell don't want to die while waiting 8 months for surgery. I would rather the nation be split into two separate countries than risk my life in the idiocy of socialism.

[evagrius]

I'm not surprised by the arguments in the column- once again, there's a supposition that high-tech, high-research health care is the standard by which to judge results.

Of course there's massive advances in cardiovascular treatments in the U.S. Considering that a diet of fatty foods combined with inactivity leads inexorably to heart disease it's not surprising that a massive amount of intellectual effort would lead to such advances- never mind that following the Mediterranean
diet leads to lower heart disease- that's not high-tech enough.

The U.S. ranks 37th on the WHO rankings for overall health results but #1 in emergency response- that's because it's hight-tech and very impressive.

It reminds me of the following apocryphal story;

NASA needed to figure out a way in which astronauts in gravity free space could write notes and observations. After millions of dollars, a gravity-free flow pen was developed.
The Russians, having a more limited budget, had to depend on a more primitive technology- they used pencils.

Really- for overall health care- the best program is excellent pre and postnatal care and nutrition. Make sure young children have all the correct nutrients, in proper proportion, and one will see a healthy adult population. It's not much...but it's soooo low-tech.

[Bruce Wilder]

Product development medical research tends to concentrate in countries, which have elaborate systems for regulating medical products, like pharmaceuticals.

The U.S. has the world's strongest pharmaceutical industry because of the FDA.

Tell Tyler Cowan that, and watch his head explode.

says...

Mr. Dewey

"I sure as hell don't want to die while waiting 8 months for surgery. I would rather the nation be split into two separate countries than risk my life in the idiocy of socialism."

Bro', ( may I call you that?)- If you don't have the dough- you'll be waiting for more than eight months- maybe like forever.

Which two countries do you want- one rich and the other poor? You already have that.

[calmo]

I'm not surprised by eva's enormously sensible post once again, but I do wonder (species: realpc person, not case) if eva thinks this is a tad studied, a tad deliberate and in the service of the Industry rather than...in the service of The Truth (species: realpc AND opponents).
Would eva think such thoughts are distractions and idle speculations --possibly partisan (imagine!) cheap shots. Or putting live ammunition in that implement that certainly looks like a firearm? Could be. Could be another high-powered rifle.

[johnchx]

Bruce Wilder wrote The U.S. has the world's strongest pharmaceutical industry because of the FDA.

Excellent point.

In fact, I dimly recall reading somewhere that many countries (especially "middle income" ones) effectively free-ride on the US regulatory process: if the FDA approves a drug, they approve it (at least provisionally) automatically. Can anyone confirm this?

In any event, public (and global) confidence in the FDA's effectiveness and objectivity is a valuable asset (which really shouldn't be squandered in an effort to score points with the religious right...but that's a topic for another day.)

says...

Most Nobel prizes in Economics go to Americans or researchers at American Universities. Does this have anything to do with single-payer health care? Maybe it is more interesting to look at what *all* sciences share with respect to the US, instead of focussing only on health-care innovation. Maybe it is a more unrestricted market for economists too, but I would guess the difference lies in the funding structure for basic research (NSF, other grants, large gifts etc.), not in the configuration of the final goods market, be it for health care products, or financial services

[rc]

great topic. appreciate this blog and everyone's insights.

the last few comments appear to imply that high-tech innovation is not necessary for good health care.

that concept aside, i am puzzled about something discussed earlier. bakho stated "[T]he bottom line is that individuals pay for health care...[I]nnovation is not connected to health care dollars."

is the implication that the health care system is relatively disconnected from research? i'm not sure i understand: aren't health care systems impacted by innovation? isn't innovation brought on by research? isn't this research done at corporations' r&d depts as well as public labs? and aren't many public labs not only funded by the state but also by the very private sector orgs that plan to bring the research to market?

thanks.

[spencer]

I write in the comments section.

Is there a way to use spell checker
without writing in word and copying it?

[Mark Thoma]

The Beta version of Firefox (2.0) spell checks the contents of forms.

[Lord]

Being wealthier we spend more on healthcare. That is what drives innovation here. I don't see that changing even if some is socialized as it already is with medicare. In fact medicare probably drives more of it than anything else as these are the primary users of it.

[donna]

We're going to lose that science edge if the current anti-science trends of the administration and the anti-Darwinists continue.

And I don't think we need a single payer system, we need basic coverage for those without insurance. Those who can afford insurance or have it provided by an employer are fine. The problem is we are all paying for those who lack any kind of insurance, and our overall health stats are worse because those people don't receive basic medical care. Coverage of prenatal care needs to be provided for as well as basic vaccinations, yearly exams, and some form of catastrophic care.

This is not a complicated issue, and I'm really fed up with those who don't want to see that it has a seriously devastating impact on our economy. People come to work sick, they get others sick, they travel through our society sick, and we are ALL worse off for it.

[Richard]

Donna: disease contagion is not the primary expense of most health plans. Complications of pregnancy, the last few years of life and chronic illness are.

Chronic illness has an impact on paying for health care and for employment in general. So if you don't opt for a single-payer plan, there must be provisions for individuals to purchase insurance. But there is a selection bias when individuals purchase insurance: in general, only the most ill purchase their own insurance. In that case, you'd require mandatory insurance for individuals, the way that vehicles have mandatory insurance.

I agree that it has an impact both on the economy and on productivity - but I don't see it as simple.

[slink/js paine]

where's fred hapgood when we need him ???

[piglet]

What an embarassing attempt to find something positive in the dismal performance of US health care, and while being at it put in some euro-bashing. Boy is this bullshit. Cowen doesn't prove any of his assertions. Where is the connection between exorbitant health care spending and medical research? As if insurance companies were funding the research... Is there any evidence that US research is responsible for the bulk of concrete medical innovations? A way to test this hypothesis would be to look at newly developed drugs in the US and elsewhere. How many of them are real innovations, and how effective are they? Most of them are me-too-drugs. Anyway, the impact of high-tech medicine on life expectancy is far overrated. Most gains in life years over the last 100 years have nothing to do with high-tech medicine. People in the US would certainly be healthier if their society were more focused on prevention and the promotion of healthy life style than on prestigious nobel prizes. The whole argument seems to me unfounded but it is very symptomatic for a certain type of reverse reasoning. If an expensive, high-tech oriented health care system yields mediocre results in direct comparison, let's just redefine the criteria of success. Let's take, er, the number of Nobel prizes instead of life expectancy or health care coverage. See how good our system really is? ;-)

[anne]

Piglet has a way of saying what is needed:

"What an embarrassing attempt to find something positive in the dismal performance of US health care, and while being at it put in some Euro-bashing."

There is an ideological fix or style to folks like this that would be comical were the comedy not so foolishly accepted as truth or at least balancing opinion these days. However, bashing Europeans really is such fun.

[JohnDewey]

piglet: "Let's take, er, the number of Nobel prizes instead of life expectancy"

How can life expectancy be a measure of health care? Life expectancy in developed countries is much more dependent on genetics and on lifestyle choices than on the quality and amount of health care.

If more nutrition and health education is needed, that's a problem with the education industry, not the health care industry. The lack of such education is not due to level of funding but rather to priorities. School systems could easily reallocate half their athletic funds to true health and nutritional education.

Please don't blame life expectancy on the restaurant industry, either. McDonald's and KFC and all the other fast food restaurants have offerred helthier fare. The public just won't buy it. Remember the McLean Deluxe?

[evagrius]

Please, Mr. Dewey- stop calling health care and education "industries". It's not quibbling. Such terminology betrays a style of thinking where everything is commodified. Would call religion an "industry"? Or politics?

Also...life expectancy is linked to health care. Good pre-natal and post-natal care has been found to be the key indicator for future health. That pre-natal and post-natal care should be an absolute given and not prone to "market forces" and the like should be obvious and is to health advocates but not, apparently, to economists.

As for health and nutrition education- that has requires a profound change in the culture- how food is viewed, its purpose, ( besides stuffing one's stomach), its social value- has to be re-examined, especially in light of the massive advertisement that fast food companies indulge in.

You have a good suggestion regarding the athletic budget of schools but all that money is practically a zero in comparison to the iconic power of Ronald and his ilk and their advertising budgets.

As for the failure of McLean- it failed because it ran exactly counter to the archetype of McDonalds it created for itself.

[JohnDewey]

evagrius: "Please, Mr. Dewey- stop calling health care and education "industries". "

Here's the definitions of industry available at the Princeton website (wordnet.princeton.edu)

1. the people or companies engaged in a particular kind of commercial enterprise;

2. the organized action of making of goods and services for sale.

Health care services and education services are definitely industries. You may argue the sector of education that is government-funded does not meet the strict definition because it's services are not for sale. Vouchers would quickly change that, of course.

[JohnDewey]

evagrius: "That pre-natal and post-natal care should be an absolute given and not prone to "market forces" and the like should be obvious and is to health advocates but not, apparently, to economists."

All goods and services in this nation are subject to market forces, whether you like it or not.

[JohnDewey]

evagrius: "As for the failure of McLean- it failed because it ran exactly counter to the archetype of McDonalds it created for itself."

It failed because people didn't want it. Pure and simple.

McDonald's invested huge sums of money promoting McLean, so it wasn't a case of people not being aware of it.

McDonald's did not create the desire for hamburgers in the U.S. Diners across the nation were selling millions before Ray Kroc bought the McDonald brothers restaurant. McDonald's is just one of many companies who made hamburgers affordable.

[piglet]

JohnDewey, I mentioned life expectancy because Cowen mentions it. He claims that US medical nobel prizes "improve life expectancy". I would also suggest that this is what most people expect from a good health care system: they expect to live longer, and more healthy. That's why they spend an awful amount of money on it (especially in the US). If better health care does not lead to a longer life, as you seem to suggest, then maybe the "health care industry" (as you call it) is ripping us off.

You might prefer to use other measures for the effectiveness of the health care system (please name them), in any case there is overwhelming consensus that the US system doesn't perform well in direct comparison with other developed countries. Cowen can't deny it but tries to attack this consensus by making claims about the effectiveness of US high tech medical research, however without providing any evidence. On the bottom line, the question is whether one judges the effectiveness of US health care pragmatically by looking at the outcome, or whether one accepts to pay more for ideological reasons.

[JohnDewey]

piglet: "in any case there is overwhelming consensus that the US system doesn't perform well in direct comparison with other developed countries"

The only objective measures I've ever seen are life expectancy and infant mortality. IMO, neither are valid for comparisons of health care delivery systems.

Life expectancy is much more dependent on genetics, lifestyle, diet, and education level than on the health care system. It is African-American life expectancies that cause the U.S. to lag Japan and much of Europe. African Americans in the U.S. have much higher incidence of AIDs, diabetes, and hypertension.

Infant mortality is not measured consistently around the world. The U.S. counts as living all infants removed from the mother tht show any evidence of life, including breathing, heart beating, or even voluntary muscle contraction. In Switxerland, infants must be 30 cm in length to even be considered living. Different regions of Italy have different definitions for infant death. Some nations do not count infants born to foreign residents.

The Center for Disease Control has determined that infant mortality is higher for women who: smoked during pregnancy; were teenagers; had less education; were unmarried; and received no prenatal care. Only the last factor can be considered a failure of the health care system, and only if prenatal care was not available. If prenatal care was available but simply ignored, the problem is not the health care delivery system.

[piglet]

It is certainly not African Americans' genetics that causes them to die early, and that causes black baby mortality to be twice as high as the average. Apart from that, I agree that life expectancy reflects on several different factors with health care being only one of them. Still, if the US health care system were worth its money, it should be possible to find some objective evidence for that. All the available evidence however seems to point in the opposite direction.

Okay, maybe it isn't health care that is to blame, but when you say that Americans' life expectancy is mediocre *despite excellent health care*, isn't this an even more damning indictment if the US social model? Why is it that factors like poverty, life style and diet are dragging US health statistics down?

Maybe the USA needs better working conditions, better social security, better public education. Maybe less high-prestige research and fewer nobel prize winners. I am just stating an hypothesis ;-) In any case, it won't do ignoring or explaining away bad statistics - as both you and Tyler Cowen are trying to do.

[anne]

Simply begin with 47 million Americans lacking health insurance, and there is a significant problem no matter how beneficial health care can be for those who have access to the finest of insurance supported care.

[Tom]

""United States spends more of its gross domestic product on medical care than any nation in the world, yet Americans do not live longer than Western Europeans or Japanese""

Japanese Americans do though live longer than Japanese, and European Americans do though live longer than Europeans.
African Americans do not do so well because of higher fat diets.
It's harder to make comparisons when not in a homogeneous country.

Spencer, I do not see Tyler defending the large government spending in the US, but usually argueing against MORE gov't spending. Libertarians argue for no gov't support.

Anne, not having health care insurance is not the same as not having health care. Of the 47 mil without it, most are new immigrants, or younger workers who don't feel they need it yet. As my allergist told me, when I explained I have no primary Physician, 'Why would any man under 40 have one.'

[JohnDewey]

Anne,

If you are claiming that patients who need medical care are dying for lack of insurace, I disagree.

If you are claiming that 47 million people do not receive any health care, I disagree.

If you are claiming that charity or medicaid pateints receive less than quality treatment doctors and nurses, I disagree.

I will acknowledge that 20% of physicians do not serve any Medicaid patients.

Are you arguing that lower income households do not receive as much healthcare as upper income households? That will always be true. It's true even in nations that have stupidly implemented socialized medicine.

[Robert]

TOm said
"Anne, not having health care insurance is not the same as not having health care."

In the purest sense of "insurance", the inclusion of actuarially least meaningful parts of the risk pool adds little to nothing to risks of the risk pool (and thus the real post-claim expenditure cost). This means (if Tom is right) that covering such uninsured for the times when unforeseen "shit happens" would add little to nothing to overall expense. But it still makes wonderful sense for health insurance costs to be evened out over the life rather than fragmenting the risk pool and pricing an 18yr old at $100yr and a 75yo at 50,000. The latter clearly creates unbridgeable gaps between healthcare "costs" and healthcare "finance".

Tom also said:

'Why would any man under 40 have one.'

Your allergist is a weenie and was lucky to be given a license to practice. There are plenty of reasons why it makes sense to have Primary Care Physician, not least that a Dr. who knows his patient has a higher chance of catching something that needs to be caught than a "stranger", in addition to it being much more efficient to be able to dispense with the introductory get-to-know-you. And humans are not carburaters, much of health is mental, and there is much wrapped up in teh social relationship with ones doctor and health and confidence that a sense of trust entails.

[evagrius]

Mr. Dewey;
"2. the organized action of making of goods and services for sale.

Health care services and education services are definitely industries. You may argue the sector of education that is government-funded does not meet the strict definition because it's (sic) services are not for sale. Vouchers would quickly change that, of course."

Health care and education are not goods and services- not really. They are necessities for a society to continue to exist- particularly a highly developed, technological one. That's why in most advanced industrial societies, these are considered to be fundamental human rights.

Vouchers are the most idiotic "solution" to the problem of access.

[evagrius]

"McDonald's invested huge sums of money promoting McLean, so it wasn't a case of people not being aware of it.

McDonald's did not create the desire for hamburgers in the U.S. Diners across the nation were selling millions before Ray Kroc bought the McDonald brothers restaurant. McDonald's is just one of many companies who made hamburgers affordable"

I did not argue that people were not aware of it- I argued that the McLean ran counter to the well-established archetype of McDonald's- a hamburger that has the "mouth-feel" of baby food.

Hamburgers were always "affordable". One cannot argue that a hamburger is haute cuisine by any means. McDonald's simply made them cheaper but not better.

[evagrius]

That pre-natal and post-natal care should be an absolute given and not prone to "market forces" and the like should be obvious and is to health advocates but not, apparently, to economists."

"All goods and services in this nation are subject to market forces, whether you like it or not."

Precisely my point. Why repeat it? Why indeed should pre and post natal care be subject to "market forces"? Are they "God"?

[evagrius]

"Life expectancy is much more dependent on genetics, lifestyle, diet, and education level than on the health care system. It is African-American life expectancies that cause the U.S. to lag Japan and much of Europe. African Americans in the U.S. have much higher incidence of AIDs, diabetes, and hypertension."

Here is the rub- why should African-Americans suffer more of these conditions than the rest of the population? Isn'ttheir health related to their socio-economic condition- to put simply, they ain't got the dough?

[evagrius]

Tom;

"Japanese Americans do though live longer than Japanese, and European Americans do though live longer than Europeans"

I'd like to see the stats on this- it might have been true about the Japanese, considering that their diet was radically improved only after WWII.
The same might be true for Europeans also, ( and I'd like to see which ones- after all, it is a rather diverse continent).

At any rate- I think your point is mistaken if one looks at present stats.

[evagrius]

"If you are claiming that patients who need medical care are dying for lack of insurace,(sic) I disagree."

Well, then, I guess you'll have to talk to uninsured people who have, say, diabetes and can't afford the insulin and other treatments.
I knew a woman who was poor, uninsured and diabetic. She neded two insulin shots a day to maintain a basic health and could not afford them. She applied for Social Security Disability, ( which would have made her eligible for Medicaid), but was turned down- the reason? Since she could work if she took insulin, she obviously was not disabled. A wonderful Catch-22.
( Fortunately, she was eventually able to obtain Medicaid after her ex-husband dumper their daughters on her- she was then eligible as a single parent ).

That's only one case- there are countless others. Open your eyes, Mr. Dewey.

"If you are claiming that 47 million people do not receive any health care, I disagree."

They may receive some health care but only at emergency clinics if it's an emergency. They do not get care for chronic diseases, like diabetes. Again, open your eyes.

"If you are claiming that charity or medicaid pateints receive less than quality treatment doctors and nurses, I disagree."

You may be right, depending on the doctor, but often they receive perfunctory care, the minimum needed and that's it. Children on Medicaid iften are the last in line for certain services such as vaccinations and the like. It often depends on where they live. If it's an affluent area or state, they can get good care. But if they live in poor states, watch out.

"I will acknowledge that 20% of physicians do not serve any Medicaid patients."

Gee, that's big of you- but I think the figure is much higher than that. It depends on the region of course.

"Are you arguing that lower income households do not receive as much healthcare as upper income households? That will always be true. It's true even in nations that have stupidly implemented socialized medicine."

Yes, it's true that higher income people receive better healthcare- but considering that other countries have far less income and therefore social inequality, your argument is a little thin.

[Richard]

Those who think there is no money to be found here don't know the nature of American culture and the multiple temptations of the word "free" (yes, indeed, we are in the land of the free) . . . .

"Dude, I get to play this video game for free for an hour, as long as I put the Stereo Sound System Helmet on my head . . . I dunno why it's free, dude, somethin about the mall association sponsoring it . . . Hey, I don't care if they broadcast nonstop psychotic thoughts directly into my brain, if they let me play ***** for free, I'm all over that."

[JohnDewey]

evagrius: "why should African-Americans suffer more of these conditions than the rest of the population? Isn'ttheir health related to their socio-economic condition- to put simply, they ain't got the dough?"

Sorry, but I don't see how substance abuse, AIDS, diabetes, and hypertension are caused by lack of money. It doesn't cost anything to not buy beer and crack cocaine. Abstinence is free and condoms are cheap. Vegetables and skinless chicken breasts cost much less than Quarter Pounders and Supersize Fries. Club memberships and spandex leotards aren't required for aerobic exercise.

My wife has worked in clinics and non-profit hospitals for thirty years. Based on what she tells me, I have trouble believing that the common medicines for life-threatening illness are unavailable to those who need them. I'm not saying that some Medicaid bureaucrats don't make mistakes. But Americans aren't dying in the streets from lack of medical care.

[calmo]

Hmm...JohnDeer the anecdotal tractor...what might make him pause, reconsider, perhaps even *listen* to those spandexed, abstinance-ignoring, beer-buyin and cocaine-crackin African Americans?
A big hug?
I don't think so --not from one of those black sambos, nosireebob.
A pair of tickets to a basketball game?
Not in Milwaukee. A football game? A baseball game then?
Ok, I'm no jock either.
What about jazz? blues? tap dancin?

The culture of poverty is impenetrable.

Time to crack that shell John (you coconut) and get some culture that is not pre-screened by your wife, who might be a dear, nonetheless for putting up with you.

[evagrius]

"Vegetables and skinless chicken breasts cost much less than Quarter Pounders and Supersize Fries. Club memberships and spandex leotards aren't required for aerobic exercise.

My wife has worked in clinics and non-profit hospitals for thirty years. Based on what she tells me, I have trouble believing that the common medicines for life-threatening illness are unavailable to those who need them. I'm not saying that some Medicaid bureaucrats don't make mistakes. But Americans aren't dying in the streets from lack of medical care."

Mr. Dewey, you're right about the beer and the crack and the sex- except that in a culture where everything's a commodity these rather cheap, on the surface, things are awful attractive to someone who knows they will never get to the Big American Dream.

And you're right- vegetables and skinless chicken does cost less than 1/4 burgers- in the right neighborhood. A number of studies have shown that few inner-city neighborhoods have grocery stores that offer fresh vegetables or good meat, ( there's a web site from Oakland, Ca that discusses a vegetable truck going to these 'hoods). They have more liquor stores and fast food joints per square mile than the more affluent neighborhoods. And remember, it costs money to cook food- gas and electricity don't come cheap.

And as for exercise- well, I suppose you can exercise outside in those neighborhoods if you can dodge the bullets and thugs.

As for getting those medicines, it isn't the fault of Medicaid eligibility workers, it's the rules themselves that prevent it. Go look them up- eligibility for single or married adults with no children is not there- and if both parents work, only the children are eligible. Please- look up those rules on your local human services website.

And no,no one's dying in the streets- they're dying in the emergency wards of hospitals- if they get service, they get kicked out and left with a whopping bill that they can't pay off. Remember, the new bankruptcy rules don't allow medical bills to be written off.

You really have to open your eyes, Mr Dewey.

[Sonia]

The disparity between African American and other American's life expectancy is not the major factor accounting for lower US life expectancy relative to many other countries. For example, overall life expectancy for females at birth is only 0.4 years below white female expectancy at birth (CDC).

Life expectancy has improved dramatically in the US in the last thirty plus years for example, life expectancy for African American males increased by nine years over the period 1970 to 2003. The difference between male and female life expectancy at age 65 has narrowed most likely at least in part due to improvements in drug and surgical technology. We don't fully understand all the causes for differences in African American and Euro American mortality and morbidity. Genetics may play a role and if so this may suggest that more research probably be focused on for example blood presure treatment.

Medical care is not only about life extension. Life style improving disability lowering technology is a major benefit even if doesn't improve life expectancy.

It is not necessary to reduce access to medical care for the fortunate majority to improve care for the e.g. 30 or 35 milllion persons who are regularly without health insurance and rely on a safety net that provides preaty good care for some (children) and often not such good care for childless adults. Take away the fear that the majority will be subject to additional non-price rationing and the public would probably support any one of a number of options for expanded health care for the mostly low and moderate income persons who do not currently have standard care. Some sort of mandate and additional subsidies for low income would be required. Some of the subsidy now provided to higher income employees through the exclusion for employer contributions for health insurance could be retargeted but overall additional resources would be required. A wealthy nation can afford this.

[Isabel]

African Americans: 13,4% (2004)
Uninsured Americans: 15,6% (2004)

Yes, I definitely agree that is the diversity that ruins the performance of the american health care system. But not the genetical one...

[anne]

Comes again the translator, translating.

[anne]

http://www.nytimes.com/2006/10/03/science/03butter.html?ex=1317528000&en=349fd72a385332f8&ei=5090&partner=rssuserland&emc=rss

October 3, 2006

Fly Away Home
By DONALD G. McNEIL Jr.

LAWRENCE, Kan. — Pinching a bright orange butterfly in one hand and an adhesive tag the size of a baby's thumbnail in the other, the entomologist bent down so his audience could watch the big moment....

[Here are butterflies just for you....]

[Isabel]

And no chocolate in the wilderness of Castilla (less dismal in the colours of autumn, thank God). Blame the free markets that make it so much more interesting to producers and distributors to pack rows of shelves with awful candy with all manner of wrapping paper that a true chocolate-lover cannot find an honest to god 70% dark chocolate bar in a petrol station when he or she needs it.
The French, on the other hand, elicited the following comment from my AH: "The French like to pose as very civilised, probably because they are!"

[anne]

http://www.calvorn.com/gallery/photo.php?photo=6910&u=96|3|...

Yellow Warbler Perched in Male Groundsel Bush (Baccharis halimifolia)
Oceanside Marine Nature Study Area--Long Island.

Color is necessary.

[anne]

http://www.calvorn.com/gallery/photo.php?photo=6911&exhibition=7&ee_lang=eng&u=16,28

Yellow Warbler Perched in Female Groundsel Bush (Baccharis halimifolia)
Oceanside Marine Nature Study Area--Long Island.

What is the difference?

[Isabel]

I've just stumbled upon this text while trying to find a shop carrying american products for my homesick American Husband. I know I will have lost it by the time it would be more relevant, so here it is anyway:

http://www.expatica.com/actual/article.asp?subchannel_id=24&story_id=33423

[anne]

Never could I allow myself to imagine what shopping for a homesick husband would amount to. Not with my imagination, the sexier the better.

[Isabel]

Food is home.

[calmo]

I'm breathless, IsabelThe French, on the other hand, elicited the following comment from my AH: "The French like to pose as very civilised, probably because they are!""probably"...
Ok, no 'probably' about it for me: I'm slobbering and drooling for your next post.

[anne]

http://www.expatica.com/actual/article.asp?subchannel_id=24&story_id=33423

September 28, 2006

Adventures in Medicine
By Veronica McCabe

I never fully appreciated my US doctors until it was time to leave for Belgium. As I collected medical records from my dentist, my family doctor, my ob/gyn, my children's paediatrician, my dermatologist, my cardiologist, our eye doctor, and our chiropractor I realized just how many people had a hand in my health and I stopped taking their care for granted....

The thought of starting over building a medical team in a foreign country where I didn't speak the language or understand the culture caused a lot of anxiety. How would I find and choose doctors in Belgium? What could I expect? Would I be comfortable with my care? Would it be on par with the care I received in the US?

The stakes were raised a few months before our move, when I was unexpectedly diagnosed with a heart condition. And after my 40th birthday, my family history of breast cancer was always lurking in the back of my mind. Despite a lifetime interest in health and fitness, I had other chronic health issues that required ongoing care. Now more than ever, I needed to have confidence in my doctors.

My first step was finding a family doctor. I received a referral from another American expat and dialled the phone with great trepidation. I was shocked when the doctor herself answered the phone—this NEVER happens in the US. Every doctor has a receptionist who handles appointments and an answering service for after hours.

I was also pleasantly surprised when she offered me an appointment the next day—and I was greeted by her promptly and had an unhurried consultation without having to fill out any paperwork. Instead of endless forms, she simply listened while I talked, jotting an occasional note on her laptop.

This was the beginning of a series of happy discoveries about medical care in Belgium. Healthcare in the US is mired in bureaucracy and competing interests and concerns about liability. It's a complex system that both doctors and patients hate for different reasons. The typical doctor must employ a receptionist to handle calls and appointments, an office manager to handle the business side (accounts receivable and insurance claims), and at least one nurse to assist the doctor and patients.

A typical doctor's visit always includes filling out paperwork, updating your medical history, submitting insurance information and waiting, waiting, and waiting to see the doctor, who is normally overworked and visibly frazzled by the incredible pace and hours he/she is expected to keep.

After 18 months in Belgium and multiple checkups, I have yet to fill out a single form, let alone the scads of paperwork I had to do in the US at every single visit. All of my medical tests have been given by doctors; in the US specially trained technicians or nurses administer tests and the results are reviewed by the doctor later.

My family doctor here in Belgium normally spends a half hour with me (compared to less than 10 minutes in the US). My cardiologist spends nearly an hour with me. My perception has been that the doctors here are conservative, cautious, and thorough in their approach, something I appreciate as I deal with more medical issues than ever before....

[anne]

Food is home? Then, the whole purpose of shopping to be to change what home is, and as far from food as possible.

[Isabel]

Strange handle for such a passionate poster!

Anyway, it's funny this obsession (love-hate?) Americans seem to have about the French. Until recently (until I've started to see the world in part through American eyes) the French for me were just... well... French. I had never realised that they were some kind of thorn on the side of the American psyche, living critique of the American way of life. I'm sure they are not aware of that themselves. They just follow their litle French ways, fairly satisfied with themselves...

And it was not always like that. My American half and I tried to figure out where that all started, but we didn't come to any conclusion. Any idea?

[anne]

http://www.nytimes.com/2006/05/17/travel/17frugaltraveler.html?ex=1160452800&en=34cda696a2c54848&ei=5070

Like Phileas Fogg, I set off without a second thought last Thursday.

Which is how I came to find myself in Lisbon last weekend, in the hip Bairro Alto neighborhood with my friend Michele, an American who's lived there a decade, and his friend Margarita. Despite my jetlag, we were drinking outdoors on Rua da Bica Duarte Belo. Lisbon's coolest were out in full force.

"Look at this guy," Michele said, nodding at a Lisboete in his mid-20's, with dark hair, dark eyes and a week's growth of beard. "He's so Portuguese. They're all so Portuguese! They all look like they could've been 16th-century explorers."

Indeed, Lisbon seems to have been designed for and by explorers. A discovery lurks around every corner, whether it's a peaceful pocket park, a glittering view of the Tagus or just the irresistible scent of roasted chicken from a takeout joint. I would spend the next two days wandering those back alleys, getting lost in the way that one only can in old European cities.

Besides, I was running low on money. I wanted to splurge on my first night, so we ended up at Farta Brutos, an old-school restaurant where the dorado comes perfectly grilled and the motherly waitress shoots you disapproving looks if you don't finish everything on your plate. Dinner set me back 25 euros....

[Isabel]

"...the irresistible scent of roasted chicken from a takeout joint."

Oh Anne, that was cruel! Food is home, indeed.

[anne]

Well; a compromise. Remember George Costanza who wanted it all, warm pastrami sandwiches, television, coupled with sex; which is, well, a bit of a challenge to say the least. Then, having coupled sex and pastrami sandwiches, you can imagine what would happen to George at the sight and smell of a sandwich alone.

[anne]

Think what we can really do in the way of behavior modification, with a little preparation.

[Isabel]

Being television-challenged myself, I recognise that that is one of the greatest difficulties of communication when living with an American (thank God for Wikipedia).

[anne]

Ah, the point then is to radically change what food represents.

[anne]

Actually, I do not think traditional Portuguese sensitivities were ready for Seinfeld at the time and possibly not quite now. Then again, there are the non-traditional Portuguese sensitivities that are become increasingly subversive. Not that there's anything wrong with it.

says...

Do you know, the French have just banned public smoking as have the Irish? That is wonderful, and there is a health measure.

[Isabel]

Actually, the ones that surprised me more were the Italians. If they can put up with a total ban, I suppose anybody can.
Will we live to see this kind of zeal applied to isoglucose and the corn/sugar lobby? I am blessed with the ability to smoke when I feel like (which I rarely chose to) without being hooked to smoking. But I am in practice unable to chose to avoid an ubiquous ingredient that has, like tabacco, no virtue apart from a (perverse) oral pleasure.

[reason]

I didn't read all comments carefully, but a quit scan didn't reveal what I guess is the real reason for research being concentrated in the US. The FDA. Convincing the FDA to approve a drug is the single most important activity of drug companies (which are increasingly concentrated in ownership worldwide). As a Libertarian, I'm sure Tyler is not likely to think of that.

[anne]

Ah, while corn sugar is widely used as a food additive, corn sugar can be surprisingly easily reduced in a diet by simply avoiding drinks with corn syrup. I never have such drinks, in favor of pure fruit juices. Smoking however is simply pernicious, and should be stopped completely whenever possible. Fortunately public smoking as well has become easily avoided. Smoking is a statistically severe problem, and smoking really is addictive. Fruit juice as a substitute for both, both especially for smoking.

[Isabel]

Unfortunately, it's more complicated than that (avoiding corn syrup, I mean). I realised that when, shopping for a boat trip, I found out that there were virtually no toasts or crackers, for example, that didn't have it. As a matter of fact, you have to avoid basically all processed food. Which I rarely use, anyway. But it does anoy me, to say the least, to have to go through a supermarket as through a minefield. And as far as can tell, Europe is not as bad as the US (not so much out of health awareness, but to protect the local beet sugar industry, if I got it right).

[anne]

http://www.nytimes.com/2006/04/23/books/review/23kamp.html?ex=1303444800&en=3c0858ed7ad112b7&ei=5090&partner=rssuserland&emc=rss

April 23, 2006

Deconstructing Dinner
By DAVID KAMP

Life is confusing atop the food chain. For most animals, eating is a simple matter of biological imperative: if you're a koala, you seek out eucalyptus leaves; if you're a prairie vole, you munch on bluegrass and clover. But Homo sapiens, encumbered by a big brain and such inventions as agriculture and industry, faces a bewildering array of choices, from scrambled eggs to Chicken McNuggets, from a bowl of fresh strawberries to the petrochemically complex yellow log of sweet, spongy food product known as the Twinkie. "When you can eat just about anything nature has to offer," Michael Pollan writes in his thoughtful, engrossing new book, "The Omnivore's Dilemma," "deciding what you should eat will inevitably stir anxiety."

Nowhere is this anxiety more acute, Pollan says, than in the United States. Wealth, abundance and the lack of a steadying, centuries-old food culture have conspired to make us Americans dysfunctional eaters, obsessed with getting thin while becoming ever more fat, lurching from one specious bit of dietary wisdom (margarine is better for you than butter) to another (carbs kill). Pollan diagnoses a "national eating disorder," and he aims to shed light on both its causes and some potential solutions. To this end, he embarks on four separate eating adventures, each of which starts at the very beginning — in the soil from which the raw materials of his dinners will emerge — and ends with a cooked, finished meal.

These meals are, in order, a McDonald's repast consumed by Pollan with his wife and son in their car as it vrooms up a California freeway; a "Big Organic" meal of ingredients purchased at the upmarket chain Whole Foods; a beyond-organic chicken dinner whose main course and side dishes come from a wondrously self-sustaining Virginia farm that uses no pesticides, antibiotics or synthetic fertilizers; and a "hunter-gatherer" feast consisting almost entirely of ingredients that Pollan has shot dead or foraged himself.

Even if the author weren't a professor of journalism at Berkeley, and therefore by definition a liberal foodie intellectual, you could guess how this scheme will play out: the McDonald's meal will be found wanting in terms of nutrition and eco-sustainability; the Whole Foods meal will be decent but tainted with a whiff of corporate compromise; the Virginia farm meal will be rapturously flavorful and uplifting; and the hunter-gatherer meal will be a gutsy feast of wild boar and morels, with a side of guilt and some squirmy philosophizing on what it means to take a pig's life.

But for Pollan, the final outcome is less important than the meal's journey from the soil to the plate. His supermeticulous reporting is the book's strength — you're not likely to get a better explanation of exactly where your food comes from. In fact, the first quarter of the book is devoted to a shocking, page-turning exposé of the secret life of that most seemingly innocent and benign of American crops, corn.

The species Zea mays, for all its connotations of heartland goodness and Rodgers and Hammerstein romance ("as high as an elephant's eye"), has been turned into nothing less than an agent of evil, Pollan argues. Expanding on his articles for The New York Times Magazine, he lays out the many ways in which government policy since the Nixon era — to grow as much corn as possible, subsidized with federal money — is totally out of whack with the needs of nature and the American public.

Big agribusiness has Washington in its pocket. The reason its titans want to keep corn cheap and plentiful, Pollan explains, is that they value it, above all, as a remarkably inexpensive industrial raw material. Not only does it fatten up a beef steer more quickly than pasture does (though at a cost to ourselves and cattle, which haven't evolved to digest corn, and are therefore pre-emptively fed antibiotics to offset the stresses caused by their unnatural diet); once milled, refined and recompounded, corn can become any number of things, from ethanol for the gas tank to dozens of edible, if not nutritious, products, like the thickener in a milkshake, the hydrogenated oil in margarine, the modified cornstarch that binds the pulverized meat in a McNugget and, most disastrously, the ubiquitous sweetener known as high-fructose corn syrup (HFCS). Though it didn't reach the American market until 1980, HFCS has insinuated itself into every nook and cranny of the larder — in Pollan's McDonald's meal, there's HFCS not only in his 32-ounce soda, but in the ketchup and the bun of his cheeseburger — and Pollan fingers it as the prime culprit in the nation's obesity epidemic....

[anne]

http://pollan.blogs.nytimes.com/?p=18

May 11, 2006

Why Eating Well Is 'Elitist'
By Michael Pollan

Thanks for all the great posts from readers — you've given me a lot to chew on, and there are many questions and comments I plan to address in future posts. But for today, I want to look briefly at the "elitism" issue raised by several of you. As you will see it also ties into the good question raised by Paul Stamler about whether consumer action — voting with your forks — is adequate to the task of changing the American way of eating.

It is a fact that to eat healthily in this country — by which I mean consuming food that contributes both to the eater's health as well as to the health of the environment — costs more than it does to eat poorly. Indeed, the rules of the game by which we eat create a situation in which it is actually rational to eat poorly.

Let's say you live on fixed income, and struggle to keep your family fed. When you go to the supermarket, you are, in effect, foraging for energy — calories — to keep your family alive. So what are you going to buy with your precious food dollar? Fresh produce? Or junk food?

A 2004 article in the American Journal of Clinical Nutrition by Adam Drewnowski and S.E. Specter offers some devastating answers. One dollar spent in the processed food section of the supermarket — the aisles in the middle of the store — will buy you 1200 calories of cookies and snacks. That same dollar spent in the produce section on the perimeter will buy you only 250 calories of carrots. Similarly, a dollar spent in the processed food aisles will buy you 875 calories of soda but only 170 calories of fruit juice. So if you're in the desperate position of shopping simply for calories to keep your family going, the rational strategy is to buy the junk.

Mr. Drewnowski explains that we are driven by our evolutionary inheritance to expend as little energy as possible seeking out as much food energy as possible. So we naturally gravitate to "energy-dense foods" — high-calorie sugars and fats, which in nature are rare and hard to find. Sugars in nature come mostly in the form of ripe fruit and, if you're really lucky, honey; fats come in the form of meat, the getting of which requires a great expense of energy, making them fairly rare in the diet as well. Well, the modern supermarket reverses the whole caloric calculus: the most energy-dense foods are the easiest — that is, cheapest — ones to acquire. If you want a concise explanation of obesity, and in particular why the most reliable predictor of obesity is one's income level, there it is.

The question is, how did energy-dense foods become so much cheaper in the supermarket than they are in the state of nature? ...

[anne]

Isabel:

Right you are, on the problem of fructose and processed foods, we are a people of corn, though fructose laden drinks are a special problem. Michael Pollan is terrific....

[Isabel]

Excelent texts, Anne. Correlation is not causation, of course, but the curve of the use of corn fructose, with its steep increase after the 80s, mimicks suspiciously the curve of obesity (in the US, that is).

I must say that food retail (supermarkets in particular) is the main cause of my weak faith in free markets (as in consumer choice).

[anne]

http://pollan.blogs.nytimes.com/?p=20

May 12, 2006

An Organic Chicken in Every Pot
By Michael Pollan

Let's take another look at "the elitism question" – the idea, trumpeted by the industrial food companies and their defenders – that because organic and other alternative foods cost more, they're an upper middle class luxury or, worse, affectation. It is true that organic food historically has cost significantly more than conventional food, but now that retailers like Wal-Mart have decided to move aggressively into organics, as reported in Friday's New York Times, that is about to change. For better or worse (and surely it will be both), Wal-Mart will for the first time bring organics into the mainstream, putting food grown without synthetic pesticides and fertilizers in reach of nearly all Americans. (The company aims to keep the price premium over conventional products to 10 percent.) Wal-Mart will single-handedly upend the argument that organic food is elitist.

This is very good news for American consumers and for the American land. Or perhaps I should say, for some of the American land and a great deal of the land in places like China and Mexico, because Wal-Mart will hasten the globalization of organic food. (Today, 10 percent of the organic foods in our markets is imported.) Like any other commodity that multinational companies lay their hands on, organic food will henceforth come from anywhere in the world it can be produced most cheaply, because the land and the labor there is cheaper than it is here. Organic food will go the way of sneakers or consumer electronics — yet another rootless commodity circulating in the global economy.

Oh, wait… I was talking about the good that will come of Wal-Mart's commitment to organic. Sorry about that. But in global capitalism it's often hard to separate the good news from the bad. I'll try again. . . .

Because of its scale, efficiency and ruthlessness, Wal-Mart will force down the price of organics, and that is a good thing for consumers who can't afford to spend any more for food than they already do. Wal-Mart will also educate Americans – many of whom have yet to learn what organic food is and how it differs from conventionally grown food.

This is an unalloyed good for the world's environment, since it will result in less pesticide and chemical fertilizer being applied to land somewhere. Whatever you think of the prospect of organic Coca Cola, when it comes – and it will come – thousands of acres of the world's corn fields (needed to make all that organic high fructose corn syrup) will no longer receive a shower of Atrazine. Okay, I know, you're probably registering some cognitive dissonance at the conjunction of the words "organic" and "high fructose corn syrup" — but keep your eye for a moment on that Atrazine.

Atrazine is an herbicide commonly applied to cornfields in America (it's been banned in Europe as a suspected carcinogen), and traces of it show up in our water and food. Does that matter? ...

[piglet]

"One dollar spent in the processed food section of the supermarket — the aisles in the middle of the store — will buy you 1200 calories of cookies and snacks. That same dollar spent in the produce section on the perimeter will buy you only 250 calories of carrots. Similarly, a dollar spent in the processed food aisles will buy you 875 calories of soda but only 170 calories of fruit juice. So if you're in the desperate position of shopping simply for calories to keep your family going, the rational strategy is to buy the junk."

That reasoning is bullshit. People in the US don't shop for calories, most of them get more than enough anyway, and of course many of those on low budget have overweight problems. People don't buy either soda or fruit juice for the calories, they buy them for drinks, and often they buy "diet" soda drinks. They do buy and ingest high-calory junk food and drinks but not as a result of a conscious decision ("I need to get as many calories as possible") and, crucially, not primarily as a result of budget pressures.

Non-processed, non-junk calories in rice, noodles, legumes, potatoes etc. are inexpensive. Budget alone cannot explain why some people prefer coke and chips, or frozen pizza, for dinner instead of rice, beans, vegetables, and diluted fruit juice. Healthy eating can be low or high budget, and it doesn't have to necessitate long preparations. It is a cultural phneomenon that precoessed food is seen as more appealing by many consumers. Once you have this preference, the less money you have, the more junky your food will be. But don't say there are no low-budget alternatives.

[Isabel]

I'll pull an Anne for Piglet:

In "The Road to Wigan Pier" George Orwell makes a comparison between the real budget that the family of a unemployed miner made for him, and the budget that someone more health conscious (one imagines, an intelectual) claimed to be able to live on. This is England, 1936, but I think it still applies, mutatis mutandis:

"The miner's family spend only tenpence a week on green vegetables and tenpence half-penny on milk (remember that one of them is a child less than three years old), and nothing on fruit; but they spend one and nine on sugar (about eight pounds of sugar, that is) and a shilling on tea. The half-crown spent on meat might represent a small joint and the materials for a stew; probably as often as not it would represent four or five tins of bully beef. The basis of their diet, therefore, is white bread and margarine, corned beef, sugared tea, and potatoes--an appalling diet.
Would it not be better if they spent more money on wholesome things like oranges and wholemeal bread or if they even, like the writer of the letter to the New Statesman, saved on fuel and ate their carrots raw? Yes, it would, but the point is that no ordinary human being is ever going to do such a thing. The ordinary human being would sooner starve than live on brown bread and raw carrots. And the peculiar evil is this, that the less money you have, the less inclined you feel to spend it on wholesome food. A millionaire may enjoy breakfasting off orange juice and Ryvita biscuits; an unemployed man doesn't. Here the tendency of which I spoke at the end of the last chapter comes into play. When you are unemployed, which is to say when you are underfed, harassed, bored, and miserable, you don't want to eat dull wholesome food. You want something a little bit 'tasty'. There is always some cheaply pleasant thing to tempt you. Let's have three pennorth of chips! Run out and buy us a twopenny ice-cream! Put the kettle on and we'll all have a nice cup of tea! That is how your mind works when you are at the P.A.C. level. White bread-and-marg and sugared tea don't nourish you to any extent, but they are nicer (at least most people think so) than brown bread-and-dripping and cold water. Unemployment is an endless misery that has got to be constantly palliated, and especially with tea, the English-man's opium. A cup of tea or even an aspirin is much better as a temporary stimulant than a crust of brown bread."

http://www.george-orwell.org/The_Road_to_Wigan_Pier/5.html

[anne]

Wonderful, Isabel :) And, oh my, do we ever shop for and are we conditioned to shop for calories. Beyond ethnicity, beyond class, beyond region, we shop for calories and the results are everywhere evident. We diet and diet, and shop for calories while dieting.