Posted Wednesday, July 13, 2011, at 10:46 AM
Researchers Lindsey Murtagh and David Ludwig have taken what sounds like a hard-line stance against childhood obesity. Super-obese kids, like the 90 lb. 3-year-old who eventually became a 400 lb. 12-year-old they describe in the Journal of the American Medical Association, should be taken from their homes and placed in foster care. "Despite the discomfort posed by state intervention, it may sometimes be necessary to protect a child," Murtagh told the Associated Press. In spite of the clinically distant tone of their words (removing a child from her home involves a lot more than "discomfort"), Murtagh and Ludwig are right. But if all you read is the commentary, you'll never know it.
Leaving aside the entertaining riffs on how far a policy like that might go in some distant, dystopian future (picture fat camps crossed with The Hunger Games), the tone of the debate their "Commentary" (it's not a research study, but an advocacy piece) has provoked is disturbing. Morbid obesity has already become a factor in considering whether a child should be placed into foster care. It's not really the obesity itself that underlies the removal of a child from a parent's custody, but the parent's documented refusal or inability to intervene or to follow dietary or exercise guidelines imposed by state or medical agencies involved in the child's care. Murtagh and Ludwig appear to be suggesting that states use that power more often and wield it as a threat more effectively, not that obese children be removed from their parent's custody from the moment they come to the state's attention. It's not the parents who haven't found a way to help their child that these advocates are targeting. It's the parents who can't or won't take the help that's being offered.
But responders, like Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania, writing for MSN, happily jump to the conclusion that all parents of obese children aren't trying. "The number of kids involved—an estimated 2 million children with body-mass above the 99th percentile—would quickly swamp already overwhelmed social service departments," he writes. Well, yes, they would—if all of those kids fit the other criteria for removal from parental custody. And raising the stakes of an argument like Murtagh and Ludwig's so that it appears to involve the removal, post-haste, of some 2 million kids from their parents is a great way to discount what they're saying entirely, which is really this: childhood obesity is a larger problem with extreme individual implications. Broad social programs, like those advocated by Caplan, are great, but getting the nation to "go on a diet together" isn't enough to target specific at-risk children. Not children as an abstract concept, but actual kids, with names, personalities, and emotions, that doctors and social workers see every day. Children for whom "putting exercise back on the menu" at schools isn't going to be enough.
Individual attention is expensive, complicated, and rarely scaleable. It makes for bad policy arguments and difficult budgetary arrangements, and, when looked at in large numbers, rarely feels practical. But it's perhaps the only approach with any hope of success in the most difficult cases. In the January issue of the New Yorker, Atul Gawande wrote about Jerry Brenner, a doctor in Camden, N.J., who found that just 1,000 people who made use of Camden's medical facilities accounted for 30 percent of its costs and set out to find those individual people and change that. His approach—addressing the situations and circumstances of specific lives that led to higher use of hopsital care—may be saving the city as much as half a million dollars a month as well as improving the health of some patients, but if advocated as a national policy: "let's find all the super-users of emergency care across the country and individually treat them all"—it sounds just as crazy as "let's put all the fat kids in foster care."
So how about this. Let's put all the fat kids in health care. Real health care, not "we can't afford any visit with any local physician and the nearest doctor who takes the state child health insurance is an hour away and has a three-month-long waiting list and so we end up in the emergency room" health care. And then, once health care and help and dietary advice and practical exercise alternatives are available, consider foster care on an individual basis in only the most extreme cases. That makes a really lame headline, but ultimately the only way to really fight childhood obesity is one kid at a time.