Famished, Fat, Fit: Global Health in a Nutshell

What is the future of global health?

–Are global famines right around the corner, as Paul Erhlich and other eco-pessimists predict?
–Are we all going to be fat blobs by the year 2100?
–Or will we finally going to get fit, live long, and prosper?

Well, we certainly know the past. Most people lived lives of food insecurity. Hunter-gatherers were subject to the whims of mother nature. Later on, the first farmers survived one locust (or human) invasion away from starvation. Until the Green Revolution of the 20th century, a Malthusian future appeared to be our destiny.

But instead of starvation, we got the opposite: fast food, sugary sweets, and a glut of carbohydrates. Today, obese people outnumber starving people. This seems an ironic twist in the human story. We lived on the edge of starvation for most of our history. Now we’re all going to die of heart disease and metabolic disorder.

Except we aren’t.

Medical progress has meant heart disease rates in rich countries have been cut in half by cholesterol medicines and improved medical procedures. For those who do have heart attacks, medical breakthroughs have sent survival rates higher and higher.

But too many of us are still too fat. What’s going to happen?

Here in the States, we have a saying that most trends start in California. I suggest a more global statement: Most trends start with the rich. A century ago only rich people had cars, and now billions drive. Air conditioning was first installed in the mansions of the wealthy. Today even the poor in rich countries have air conditioning, and it’s becoming commonplace in middle and low income countries. Today the global rich go to the gym, sweat through Zumba or Barre classes, and eat lots of vegetables. Tomorrow everybody will be in the gym and eating vegetables.

I’m pretty confident. Why?

Because eventually, most everybody gets everything. When smartphones first came out, only the rich had them. Now farmers in poor countries use smartphones to get information about the weather and crop prices. TVs were once curiosities in the homes of the wealthy. Now people in favelas, barrios, and slums around the world watch TV.

If you think my argument’s dubious, just do a quick historical review of all the curiosities that the rich bought first and everyone else wanted. If the technology had legs–think transistor radios, TV, smartphones…not Segways and Furbies–then eventually these popular products were made and marketed for the masses.

But eating less and exercising more is a behavior, not a product.

Smoking provides the best example of the pattern I describe. Lots of people smoked a generation ago. As laws and customs in wealthy countries become more smoker unfriendly, the culture started to shift. Who were the first adopters of a new smoke-free lifestyle? The rich and highly educated. Income and education attainment have a strong reverse correlation with smoking. So as more and more people get better educated and earn more, they will smoke less. Similarly, as education and income go up, obesity goes down. The same process that gets people to eat less and exercise more is the one that got folks to smoke less.

Here’s how the Population Reference Bureau put it: “(R)esearchers found that activities such as reading, attending cultural events, and going to the movies were associated just as much as exercise was with a lower BMI. On the other hand, people who participated in activities such as watching TV, attending sporting events, and shopping had higher BMI. These patterns were most consistent in high-income nations….” More and more people are moving toward high income…and nerd-dom. Yes, part of growing wealthy is becoming boring: reading books, going to cultural events, etc. But that’s where people are heading, on an upward income and education escalator, what economist Steven Radalet calls “The Great Surge” and Nobel-prize winner Angus Deaton calls “The Great Escape” from poverty.

So I’m not a health economist, but I’m going to say this anyway: Humans go through three stages: Famished, Fat, and Fit. For 99% of history most of us have been living one really bad day (or event) away from famine. For the last couple generations, folks in rich countries have been getting fat. Most recently, the rich and middle classes of rich countries have been eating more vegetables and exercising (just like they stopped smoking 30 years ago). The income and education escalator will bring the rest of the world up to the Fit stage someday, and probably sooner than we think. It took less than 10 years for the iPhone to go from plaything of the rich to global ubiquity. Invest in gym memberships and health food!

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