What of those who ruin their health?
In addition to being a fine actor, James Gandolfini was smart and rich. He could afford the best medical care the West has to offer and understand the stakes of being so overweight and stressed. Yet he let his weight balloon in an orgy of careless eating and drinking. Did he think himself invincible or assume that he had time to deal with health issues later, his age being only 51? Surely a doctor somewhere read him the riot act, so why didn't he make health a priority?
This is something I'd like to know.
We've seen highly educated people fully aware of the facts nonetheless abuse their bodies through obesity, alcoholism or smoking. Sometimes their lack of self care is so extraordinary that we wonder whether they are suicidal. But then, when diagnosed with the predictable dread disease, they undergo any expense and gruesome treatment to stay alive.
The writer Christopher Hitchens was brilliant in many ways, but he died at 62 of esophageal cancer tied to his chain smoking. Asked about his smoking habit in a 1995 interview, Hitchens dismissed the concern with his trademark bravado, saying, "I don't want to live forever." But from his first race to an emergency room to his death 18 months later, he subjected himself to every awful treatment offered at the most cutting-edge facility.
The American Medical Association recently classified obesity as a disease, though many within the doctors organization disagree. It's not entirely clear what constitutes a disease or obesity. The body mass index used to define it is considered a primitive tool.
The question arises, though: If obesity is a disease - as some consider addictions to alcohol or cigarettes - what kind of disease is it? Is it chiefly biomedical or psychological? No doubt some have a biological tendency to put on weight, but it is clear that obesity is related to low education and low income.
That's why obesity and the attendant diabetes run rampant in poor populations. Here patients often ignore all dietary advice. They may not take their blood-pressure medicine. They might not see a doctor at a community clinic if it means waiting a few weeks.
Even though the Affordable Care Act will generously subsidize health coverage for low-income Americans, some doctors fear many won't seek medical care if that means paying the smallest of copayments. Preventive medicine has little meaning in some communities, where health risks that could be minimized with simple self care end up as catastrophes in emergency rooms.
The health care reforms will give the community clinics treating the poor $11 billion over five years to meet the growing demands. But suppose their medical providers can't get through to the passively sick, despite the greater resources. Dealing with a chronic condition requires lots of follow-up and dedication on the patient's part.
In states that participate in the Medicaid expansion, the poorest will get virtually free medical care and drugs, but might have to shell out for a few items. Some health care professionals worry, based on their experience, that many low-income patients won't spend even a small sum for their medical care.
This seems so far from the other America, land of the organized and the super-fit. Here the citizens sweat, they meditate, they do yoga. If a fingernail cracks, they take a dietary supplement.
But what to do about the smokers, the heavy drinkers, the overeaters and the stress machines unwilling to slow the train speeding toward their demise? Providing medical advice and psychological counseling is a worthy effort, but - and this is a pessimistic ending - perhaps some people can't be helped.
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