HJAR Jan/Feb 2024

HEALTHCARE JOURNAL OF ARKANSAS I  JAN / FEB 2024 15 franchised grocery stores that strategically po- sition their lower margin, often healthier prod- ucts along the edges or periphery of the store, with higher margin processed foods dominat- ing the centrally located shelf positions that get the most customer traffic. Indeed, tons of dollars are spent on marketing research to help guide where to strategically position products to increase sales. Some may point out that the purpose of any business is to generate a profit margin. Others may argue that doing so responsibly is in the best interest of society. Socially conscious businesses tend to embrace an economic philosophy founded more around economies of scope, where the central strategic question instead becomes, “What else do cus- tomers need?” In healthcare, I would contend the answer to that question is “better health.” As discussed in prior articles, traditional healthcare has confronted a similar strategic dilemma as it relates to primary care, which is currently not all designed to confront this obesity epidemic. Like our grocery store anal- ogy, primary care has been referred to as the “milk in the back of the store,” identifying it as a loss leader for these traditional hospitals and health systems. Just like consumers must walk through a grocery store — being tempted to purchase an assortment of higher margin processed foods along the way — to reach the milk in the back, traditional health systems of- ten think of primary care as a money loser that serves to “feed” their higher revenue service lines. Grocery stores do not generate much if any margin on the milk they sell, but at least it gets customers through the door, thereby driving sales of their higher margin products. Sadly, fueled largely by the traditional transac- tion-based financing mechanisms from com- mercial payers along with antiquated thinking regarding the value of primary care, the same thing happens under reinvented business mod- have come a long way with the design and development of smoking cessation programs and therapies augmented by other tools and strategies to help people quit smoking. We are clearly in the midst of yet another epidemic, one that is every bit as serious and deadly as lung cancer — the obesity epidem- ic. In 1950, the prevalence of obesity among adults in the U.S. was only 10%. By 2020, it has quadrupled to around 40%. The root causes are multifactorial and complex in nature. In 1950, most people ate real food — like lean meats, fruits, vegetables, dairy products, and legumes — that they prepared at home. Today, dining out in restaurants is more common than it was in 1950 and today’s restaurants serve larger portions than they did in 1950. American din- ner plate manufacturers have increased the average size of a plate from 9.6 inches to 11.8 inches. The advent of television, electronics, video gaming, and other forms of screen time have resulted in a relative increase in sedentary over physical activity. Perhaps most importantly though, we also buy and consume more pro- cessed food than ever before. Additives to pro- cessed food products are designed to make them bigger, tastier, and more appealing to consumers with a singular goal in mind — to sell more product. Economies of scale reign supreme in the food industry where the cen- tral strategic business question is, “How much more stuff can we sell?” Nowhere is that clearer than in the franchised fast-food industry, which has invested so much time and marketing effort into selling as much as possible while produc- ing food that is very high in caloric content but very low in nutritional value. These companies are constantly researching how to increase sales by tweaking their ingredients to find the exact right configurations of fat, salt, and sugar that create cravings in the brain and drive an in- satiable demand for more. The same is true of Epidemics and pandemics have certainly re- curred throughout history. Prior to the discov- ery of antibiotics and epidemiological discov- eries related to sanitation and hygiene, there were epidemics related to bacterial pathogens like plague and cholera. Nowadays, infectious epidemics or pandemics mostly tend to be viral and respiratory in nature, like the great H1N1 influenza pandemic of 1918 or the more recent COVID-19 pandemic. But epidemics are no longer purely infectious in origin. They can also be driven by advances in technology, economic forces, or changes in human behavior. Accord- ing to an article written by Robert N. Proctor, PhD, a Stanford University science historian, “Lung cancer was once a very rare disease, so rare that doctors took special notice when confronted with a case, thinking it a once-in-a- lifetime oddity. Mechanization and mass mar- keting towards the end of the 19th century pop- ularized the cigarette habit however, causing a global lung cancer epidemic. Cigarettes were recognized as the cause of the epidemic in the 1940s and 1950s, with the confluence of studies from epidemiology, animal experiments, cel- lular pathology, and chemical analytics. Ciga- rette manufacturers disputed this evidence, as part of an orchestrated conspiracy to salvage cigarette sales.” 1 One of the founders of the health system where I currently work was Alton Ochsner, MD. His persistent belief in this new- est epidemic, “that cigarette smoking was the principal cause of the growing epidemic of lung cancer — a theory he publicized throughout the 1940s in the face of ridicule and vituperative attacks even from within the medical profession — symbolized his energetic drive to improve public health.” 2 Subsequent tobacco control policies, including cigarette taxes, smoke-free air laws, and cessation treatment policies have substantially reduced cigarette smoking and smoking-attributable deaths. In addition, we 1 Proctor, R.N. “The history of the discovery of the cigarette-lung cancer link: evidentiary traditions, corporate denial, and global toll.” BMJ, Tobacco Control, 21, issue 2 (Feb. 16, 1012): 87:91. doi: 10.1136/tobaccocontrol-2011-050338 2 Blum, A. “Alton Ochsner, MD, 1896-1981 Anti-Smoking Pioneer.” The Ochsner Journal 1, issue 3 (July 1999): 102:105. PMID: 21845126 History has a way of repeating itself. That much is certain. The biggest question we must ask ourselves is whether we have learned its lessons, which becomes wisdom, or whether we have failed to do so, which is foolishness.