This week’s column is about two apparently unrelated events: my re-reading of The Citadel, by AJ Cronin, a classic novel/tearjerker about a British General Practitioner, written in 1937, and the new nutrition guidelines from HHS put forward by RFK Jr. There is a common thread, I promise, which is that medicine and health are not the same: that what we want is health but what we do is medicine, and that’s crazy, because health requires us to eat well and exercise, to spend time with people we love, to take care of one another, and to govern ourselves with decency and respect.
The Citadel was written by AJ Cronin in 1937 and was set in the years after 1921, in the coal mining villages of Wales, in Great Britian. It is about the life of one Andrew Manson, a newly minted doctor, and his first job out of medical school as a doctor’s assistant. Manson is broke but idealistic; an orphan and carrying the loans he used to pay for medical school and so completely alone in the world. He quickly discovers the difficult underside to medicine – he is exploited by the unscrupulous wife of the crippled doctor he signed on to assist – but who isn’t able to help him — so Manson must care for all the doctor’s patients himself — and teach himself medicine in the process. He falls in love, marries, and finds himself in his own commitment to the science of medicine and the people he cares for. He gets a new job — and then finds the doctor who runs that practice, though well qualified, is also corrupt and profits off his assistants, who struggle to get ahead. He has conflicts with other doctors and with their employer, a union, even as he makes discoveries about an illness that besets the miners he cares for. He goes off to London, and is seduced, first, by money itself, and then by another woman, even as his practice itself becomes corrupt and he sells out. There is tragedy, repentance, reconciliation and then tragedy again, and finally the rededication to his profession, integrity, and science.
What’s remarkable about the Citadel, which was a huge bestseller in its time (it led to the creation of the British National Health Service), is that it is at once a love story and an exposè of the seedy side of the medicine of its day – and that we struggle with many of the same problems, a hundred years later. Medicine is a limited science, that can only accomplish so much – it can’t get people to act decently toward one another, and it can’t fix the harm we do to one another in our mines and factories. Medicine is frequently perverted by people who use it to extract wealth from the poor and the sick. Doctors take advantage of one another and are sometimes corrupt. But we can change for the better, Cronin says, by making our choices with integrity, and by choosing a medicine that is for people, not-for-profit and based on science, not graft.
Also this week, RFK Jr and HHS released a new food pyramid, which puts new emphasis on protein and fats, as it critiques ultra processed foods. Food is medicine, his letter says. Eat more red meat and whole milk, the recommendations say. The science behind the recommendation to eat more red meat and drink whole milk is weak (and one wonders, perhaps due to the influence of the beef and dairy lobbies, which have used their influence to upend government nutrition recommendations before), but the rest of these recommendations aren’t terrible.
Still, there are two errors. First, while many ultra processed food-like products are downright dangerous and shouldn’t be allowed on the market, let alone ever consumed, Bobby’s new food pyramid misses the single most important food related threat to America’s health. Not ultra processed foods, as noxious and dangerous as they are. Not protein. Or fat. Or even simple carbohydrates. Our single greatest threat is calories. The greatest threat to America’s health is that we eat too much (and don’t get enough exercise.) Bobby missed the opportunity to say, loud and clear, the first thing to do about food is to eat less. Or, as Michael Pollan said about twenty years ago, “Eat food. Not too much. Mostly plants.” That’s still better advice than what Bobby came up with.
And then, somewhat perversely (because Bobby wasn’t trained to practice medicine himself and appears not to know what medicine actually is, even though he is the Secretary of HHS) Bobby says food is medicine. I think he means to say that we can make America healthier if people improve their diets, which is true. But medicine is the discipline of using specific treatments to cure or improve specific diseases. When you say food is medicine, you are saying that we are all sick and we need treatment.
But food is food. We need it to live. When our businesses and our culture poison our food or profit by getting us to eat too much of it, we can cause disease. But the poor health outcomes that result from food is a social problem, not a medical one.
Public health depends on our political choices and our culture, not our medicine. Medicine might be able to compensate for some of the damage that our choices cause. But it’s crazy to think that food is medicine or medicine is health. Health is the ability to have and be in relationships. Medicine can help restore the health of individuals, to some degree, sometimes. But medicine can’t fix our relationships, any more than it can fix our food choices. Only we can improve our food choices and relationships. By listening and thinking together, and by taking care of one another. And not by taking some drug.
Join Michael Fine’s substack https://michaelfinemd.substack.com/and and received his commentaries and short stories in your inbox —https://michaelfinemd.substack.com/and on http://www.michaelfinemd.com