The Medicine

by Karen Hitchcock

  Ostensibly cheap food heavily taxes both the individual and the community in terms of disease and redirected health resources. If longevity and the avoidance of disease remain among humanity’s aims, we should try to prevent ourselves from getting very fat. Forget obesity as a disease; it’s a ruse. For whatever reason, the majority of the population can no longer say “I have had enough”. For whatever reason, the majority of human beings respond to advertisements inviting them to enter a pleasure state by eating a day’s worth of calories in one sitting, again and again. In the face of this, we are stuffed. We could say, “You are free agents, totally free, so pay for your own consequences.” We could make people pay at the point of choice, via a food tax, or we could limit choice. The other option, always unspoken, is: let us have our cake. Let’s just eat and eat, get fatter and fatter, and work out how best to live with it. This is where we are heading now: fatness, outside of morality, as an accepted consequence of the world as we have made it.

  We can decide as a country, as a world, that we are going to consume what we have until we’re done, eating as much as we wish and treating all the concomitant diseases by diverting substantial amounts of government revenue into medicine and pharmaceuticals. If we do choose this path – and we are most of the way there already – we must be honest about what we are choosing to do: to spend our country’s money on the aftermath of indiscriminate consumption.

  If you come to me, your doctor, and you ask me to make you thin, for now I will have to cut you or drug you, as these are the only weapons I have to ward off the sirens. There will come a time when patients stop asking their doctors to make them thin. It will either be because fatness is rare again, or because it has become entirely accepted. The choice is in your hands. Are you going to eat it?

  “Fat City” Revisited

  There is a group of hip-hop dancers in Melbourne who regularly perform along Swanston Street. Most of them are wiry Asians who can bend their limbs like plasticine. But my favourite dancer is an overweight Middle Eastern boy; he pounds that concrete, every bit as fit as his skinny mates. Moving deftly through space-time, he makes the others look boring – like belly dancers without the wobble. When there’s a pause in the music, he does that self-conscious thing you see blokes with bellies do: give the front of their T-shirt a little tug outwards so it hangs in front of their gut like a curtain. Women have similar moves: pulling their skirt out, or their shirt down at the back. It’s enough to break your heart, all of us walking around trying to hide.

  So when I heard about Nothing to Lose, a critically acclaimed dance production billed as a radical challenge to our perceptions of the fat body, I couldn’t wait to see it. What a terrific thing, I thought, to show that one can be fat and fit, fat and healthy, fat and unashamed.

  I was widely attacked by the body-positivity movement for my 2013 Monthly essay “Fat City”. I was accused of being moralistic and fat-hating, despite my conclusion that society must tackle the epidemic without moralising, that we must take social responsibility for creating a world where it is hard not to be fat. I still work once a week alongside the bariatric surgeons in a publicly funded obesity clinic. Patients join the long waiting list because they want help, because they are suffering the dire consequences of living obesely for decades. Their joints are destroyed; their diabetes is wreaking havoc in their kidneys, nerves and blood vessels. Their hearts are stressed and their lungs cannot clear the carbon dioxide in their blood because the fat on their torsos is so heavy. When they were twenty and fat, their bodies were still healthy.

  Tess Holliday is a young body-acceptance blogger and size-26 model. She has the face and the online following of a movie star. She is considered a role model by tens of thousands of overweight (mainly) women who say she has helped them to stop hating themselves, to feel beautiful.

  That women’s bodies are objectified, commodified and assaulted by a media that serves corporate interests is undeniable. Beauty is culturally constructed, narrowly defined and dangled like bait in countless shops. But let’s face it, hardly anyone is “beautiful”. Most of us are average, with a few funny bits. Body-hatred starts with the belief that for a woman to have worth she must be beautiful. Challenging and attempting to broaden what is considered “beautiful” is not a radical, feminist act; it is a buy-in. We should tell our daughters they don’t need to be beautiful (however this is defined) to be successful, worthwhile or happy. They don’t need to expend energy on a delusion.

  France, following Spain, Italy and Israel, recently banned underweight models because of concerns that they glorify and encourage the pursuit of an unhealthily low body weight. There were a few grumbles – about the possibility of being “naturally” extremely thin or remaining healthy at these weights – but most people supported the ban. I imagine there’d be a riot if Tess Holliday were banned from modelling until she reached a “healthy” BMI. It would be seen as a misogynist act of discrimination: proof of body-hate. Fat-positive blogger Georgina Horne changed her diet and started working out. Unsurprisingly, she lost weight. There was online debate and wide censure: she’d sold out. Some of her followers felt betrayed.

  I put it to you that the corporeal extremes – being very fat or very thin – are not about beauty or ugliness; they are about turning one’s back on wellbeing and longevity. If you can’t walk without injuring your knees or ulcerating the skin between your thighs, then that is a problem, however you or the world judges the shape of them. Caring for oneself is an act, not a state of mind.

  It is a difficult truth that raising awareness of the health implications of obesity can cause the obese to feel pain and intensify their self-loathing. So might grotesque pictures on a cigarette packet. No one wants anyone to feel like shit, but being seriously overweight is not a disease-state one is powerless to change. Will getting fit and losing some fat involve a degree of deprivation and suffering? Probably. But not as much deprivation and suffering as one may encounter in later life if one remains morbidly obese. Fat-positive activists are seriously stacking the odds against their future wellbeing. Some moderately obese people can retain cardiovascular health – those who exercise, have resilient joints and, through genetic luck, do not get diabetes (just as not everyone who smokes gets a tobacco-related disease). Health-at-any-size is possible but not probable. The current problem with our public-health approach to obesity is that we raise awareness without support and leave obesogenic structures intact. Other countries are doing better: funding exercise classes and helplines, taxing crap food, investing in movement-promoting infrastructure.

  I am uninterested in both the aesthetics and the morality of obesity, except insofar as they are barriers to us finding a solution to the medical and population-health mayhem that obesity is causing. If we make this about identity politics, beauty and acceptance, many will end up sick. Obesity is a political issue: take a look at the socio-economic maps of its prevalence. It is about our responsibility for supporting and funding public health. It is about consumerism, and unrestrained corporate greed.

  The Nothing to Lose performers did not dance. There was regal posing, strutting in underwear and the infliction of pain. They were angry and defiant, sick of being ashamed, judged and bullied. Good on them. But the obese are not a minority group in need of advocacy. They are 30 per cent of this country. And getting very fat – like smoking or drinking to excess – is self-destructive; it is an act of body-hate against oneself. The show was moving, but the title was a lie.

  Precious Sleep

  Legend has it that Margaret Thatcher needed only four hours’ sleep each night. It’s probably not true that that’s all she needed, though like some kind of sleep anorexic it may have been all she allowed herself. Mean appetites don’t tend to arise “naturally”. We’re greedy little animals when it comes to our so-called vegetative functions (sleeping, eating, drinking, sex). Sleep deprivation may even have accounted for Thatcher’s (equally legendary) hair-trigger tempers and baseline vile mood. Spending your wh
ole life dog-tired, hungry, thirsty or sexually frustrated effectively turns anyone into an arsehole.

  Last night, I slept for ten hours. For the first time in months I woke gradually to a clear, benevolent world. My vision was sharp, the air soft. It’s pretty rare for a working urbanite to sleep long and sound, and wake full term. And it’s unusual for us to allow something that feels this good to occur so rarely. You’d think we would have worked out some efficient and cheap way of fulfilling our requirements. After all, we can deal with the other basic bodily functions in this way: fast food, water bottles, porn. Why can’t we deliver a big fat sleep in a way that takes up less of our time?

  Sleep can be a slippery little sucker, even when you have the time and the appetite for it. Doctors advise insomniacs to attend to their “sleep hygiene”, as if beds are some kind of viraemic cesspool that might be cleaned up with a splash of bleach. Michael Jackson bought and controlled his sleep with a nightly physician-delivered anaesthetic. It was the kind they give you before a colonoscopy and ask you to count to ten. Any substance that offers an extended period of knockout brings with it a decent chance of death. And most of the drugs that can give us a few hours of sleep on demand are extremely addictive. We haven’t figured out a safe way of buying and selling high-quality sleep, of getting it whenever and wherever we want – or how to get, in a packet, whatever it is that sleep gives us.

  I was an insomniac child. Terrified to go to sleep, and then awake through the early hours. I don’t remember fatigue. Just the terrible wait for morning, intermittently peering behind the blind, hoping the orange crack was no longer from the sodium lamp, but from the sun. If I’d been taken to a doctor I may have been given a handful of diagnoses. Difficulty falling asleep: anxiety. Early-morning wakening: depression.

  Patients rarely report sleeping abundantly and well. They nap on the couch, at their desk, some more at the wheel. Or they’ve got it down to six hours and five coffees, supplemented with long catch-ups on the weekend. Or their soft bed, no matter how early they take to it, becomes a lumpen torture chamber lined with strangling damp sheets. Who hasn’t fallen exhausted into bed, hoping for respite, a little annihilation, only to find – the moment head and pillow collide – that their heart has been ousted by a crazed bat?

  Sleep demands that we relinquish vigilance and embrace solitude. We dream thoughts we didn’t even know we had, in full-colour, 3D playgrounds. We must close our eyes and surrender, as if to death.

  I once heard a colleague being interviewed on the radio about the ubiquity of chronic sleep deprivation. He asked the interviewer if she woke to her alarm. Yes, of course she did. “Well,” he primly said, “that means you don’t go to bed early enough.” The announcer gave a no-shit-Sherlock pause and then reeled off her excuses, ones we all know and would ourselves offer. We trade sleep for life. For non-work life. We trade it to talk and watch and eat and drink and relax and play. I’d happily pay with a day of feeling wobbly to watch a couple more episodes of UnREAL.

  When I first heard about the Iron Lady’s four-hour regimen, I was jealous. All those extra hours of consciousness. I did the sums: she’d earned herself thirteen bonus years. Maybe that additional stretch would be worth the lifetime spent feeling like crap? But sleep deprivation is not good for you. Apart from all the diseases it causes or accelerates, it also leads to impaired decision-making, a decline in empathy, a shrinking of perspective. A kind of recipe for neoliberalism.

  Time – to paraphrase Seneca – is the most precious thing we have and the thing we most thoughtlessly squander. Thatcher and her four hours functioned as a paragon to which all good citizens should aspire. Why waste time sleeping like a weakling when you could be awake producing and profiting? And when that’s the goal, enough’s never enough. Should some mad scientist work out a way to keep us all going without sleep, we’d just polyfill the extra time and then want more.

  We can rush and cram, lull and white-noise through our days. But, come night, we must climb into bed and close our eyes, if only to be reminded that our hours are limited, our life finite, our time priceless and relentlessly shrinking. Perhaps the epidemic of disordered sleep is actually a disorder of the way we are – or are not – living.

  A Former Smoker’s Lament

  I started smoking in high school and happily dedicated myself to the practice for ten years. Ex-smokers adore reminiscing – our favourite brands, when we started and stopped, the best cigarette of the day, what it was like to exhale a magnificent plume on a freezing cold morning. We’re like nostalgic diggers who discover we all knew the same guy, a most loyal and lovable soldier, and are desperate to share our tales. Friends who were never smokers listen with what-the-fucks plastered all over their faces.

  In June 2015, there was a riot in a men’s prison in Melbourne, apparently in response to a statewide smoking ban due to take effect the following day. The prison sits on a body of barren government land, Ravenhall, a few hundred metres from where I grew up. When I was a kid, my dad was mates with a sheep farmer who rented Ravenhall for his flock. Dad kept an eye on the property during the weekends, pulling out lambs stuck mid-birth, shooting hundreds of rabbits for dinners. My grandmother owned the land next door, until the government hit her with an involuntary-acquisition order, razed her almond orchard and built a women’s prison next to the men’s one. I imagine them all, locked behind concrete, being “rehabilitated”, on the paddocks of my youth. And now they can’t even smoke.

  There was an enormous drainpipe near my childhood street that stretched for 2 kilometres under houses and roads and paddocks until it stopped at a little chimney you could climb up into and peer out straight into Ravenhall. My friends and I would skip school and make the trek through the pipe, a voluntary, illicit entrapment that felt like freedom. We always made sure we had cigarettes in our pockets, but we never actually smoked them in the pitch-black of the drainpipe. It’s a funny thing about smoking I’ve often discussed with my ex-smoker friends: there’s little pleasure if you can’t see the smoke coming out of your mouth. That smooth stream of white – a willed act of creation, like art.

  I recently took a friend to see the pipe. We found the opening barred with a heavy iron grate. Maybe to keep the kids out. Or – thinking of drug lord El Chapo’s tunnel escape from a Mexican jail – maybe to keep the prisoners in.

  In 2010 I read Susannah Hunnewell’s interview with Michel Houellebecq. Hunnewell noted that throughout the two days she spent with the French author, he continually smoked something she called an electronic cigarette. “It glowed red when he inhaled, producing steam instead of smoke.” I’d never heard of electronic cigarettes and I hadn’t had a cigarette for sixteen years, but my pulse quickened. I researched online. The steam was repeatedly described as “harmless water vapour”. Imagine, I thought, being able to once again form those great white plumes, without getting emphysema. It was years before every hipster at a tram stop would be holding elaborate vaping devices, blowing steam like bearded dragons. They weren’t yet available in Australia, so I ordered a few kits from the US. I chose the elegant, pencil-thin black devices and imagined myself swanning to breakfast at Tiffany’s. Unfortunately, the taste was oily and repugnant, and it seemed to me that the stuff going in and out of my lungs contained a lot more than water.

  By 2013 all the large cigarette companies were marketing and selling e-cigarettes. And they’re using the same old tricks they’ve used for decades to promote combustible tobacco: funding consumer-rights groups, fudging health claims, lobbying regulatory agencies, deploying celebrity drones. Studies to date show that while these devices are likely less harmful than real cigarettes, they do contain multiple toxins, usually don’t lead to smoking cessation, and probably initiate young people into smoking the real thing. Yet another corporate promise of safe, easy pleasure shattered.

  As a child, cigarettes were an integral part of my nascent identity. They were potent symbols of freedom, a small act of rebellion against what were hundreds of a
dult-generated interdicts. Adolescence: one long riot. Now, I read about Big Tobacco and hear them declare their “commitment to harm reduction” and find it troubling that I might be writing a kind of love song to their evil goods. How much of the rebellious freedom I felt while I smoked was the result of their insidious marketing? Was it simply a case of addiction?

  The word “addiction” has always made me twitchy. It seems like one of those words specifically designed to arrest thinking. A word you can wield like a lasso, simplifying and reducing any individual to whom it is applied into a silent, captive beast: “I accidentally smoked ice and now my brain cells are forcing me to continue.” The websites of addiction specialists argue that any non-neurobiological explanation is moralistic. It’s all in the brain, it’s all about reward centres and dopamine feedback loops.

  Countless international professorial hours over decades have been spent debating exactly what term to use to describe and thus diagnose someone’s problematic use of a substance. “Addiction” was dumped for “dependence”, and now the preferred terminology is “substance use disorder”. According to the most recent Diagnostic and Statistical Manual of Mental Disorders (psychiatry’s bible), if the use or desire for a substance leads to clinically significant distress or impairment, you’ve got a disorder.

  My beloved period of smoking caused me no distress beyond the occasional school detention and has left me with no significant impairments. So I suppose I escape a psychiatric diagnosis. I quit – and stay quit – because I really don’t want to die. But if I wasn’t lucky enough to desperately want to live – and if I hadn’t forged better ways to assert my freedom – I know I’d still smoke my guts out. And were I in prison, I too would riot.

  A Fine Line