Abdul Mughees
Consider the word “lifestyle”. It has the sound of free choice: a man picks his life as he picks a shirt. It is also the word we reach for when we ask why so many Pakistanis are ill. The International Diabetes Federation counts 34.5 million adults here with diabetes, a rate of 31.4 per cent, the highest it records anywhere. Heart disease is among the leading causes of death. Sleep apnoea, in which the throat closes during sleep and breathing stops for seconds at a time, is common too, especially among heavier people. Set the word “lifestyle” beside these figures and see what it does. It lays the whole weight on the patient and never says so.
We treat the three separately because they are not one disease. But the same short list of causes makes each more likely: fat at the waist, too little walking, tobacco, a diet rich in refined flour, sugar and oil, and broken sleep. Each item is supported by research. That this one list serves all three is my own conclusion, drawn from laying the studies side by side.
Each item can be changed. Not one is chosen in an empty room. A man cannot buy fruit that costs more than he has. A woman cannot walk where there is nowhere to walk. A patient cannot test his blood twice a day with a machine he does not own. The easy explanation is that we have grown careless: too much rice, too much sitting, too little effort. There is something in it, and it costs nothing to say.
Take walking. The World Health Organisation reckons that 44 per cent of Pakistani adults move too little, rising to 56 per cent among women. So, we advise them to walk. But where? The park gate is locked. The footpath, where there is one, is a parking space. The lane belongs to motorcycles. Tell these people to walk more and you have said nothing to them. You have merely relieved yourself of the subject.
Food is the same. A family does not shop with a nutrition table in its hand. It shops by price, by what the corner store keeps, by what can be cooked after a day’s work and by what the children will eat. A cheap plate that fills the stomach is reasonable in a poor house, even when it is not healthy. To call that carelessness is to use a word that flatters the speaker.
Too much fat is one of the plainest warnings medicine has. What it does is the point. It goes with insulin resistance, unhealthy blood fats, raised blood pressure and a throat more likely to close at night. Most of what we know comes from studies that photograph a population at one point in time. They can show that obesity and diabetes occur together, that apnoea is common in heavier patients and that few of us walk. They cannot say how much of one caused the other.
A man may have stopped walking because he was ill. Poverty puts care out of reach, and illness empties the purse. Fat spoils sleep, and poor sleep helps keep the fat on. The arrows run both ways.
The honest claim is the smaller one: several of the chief risks can be changed, and most are shaped by how people are obliged to live. That is enough to act on. Yet we talk as though advice were free. A clinic may be within reach, but its sixth visit may not be. A drug may exist, but a year’s supply may not be affordable. A doctor may order blood checks twice a day and never ask who buys the strips.
In a survey of 600 Pakistanis with diabetes, three in five said they could not afford the machine that takes the reading. We tell patients what they ought to do and take little interest in what they can do. Between those two verbs lies most of the trouble.
Diabetes shows it best. The work starts at diagnosis and repeats every day: what to eat, when to walk, which tablet to take and which number to watch. Money worries, a bad night and low spirits make that labour heavier. A system that waits for the foot ulcer, the stroke or the hospital ward, then pays for them, is not thrifty. It is paying late.
It is agreeable to sort the sick into the careful and the careless. It is also useless. The smoker should be helped to stop, the heavier patient helped to lose weight, and the person with diabetes kept moving and kept on treatment. But society has a share, and its share is the part that can be written down.
If tobacco harms, govern how it is sold and advertised. If sweet drinks crowd out better choices, look at taxes and labels. If walking keeps people well, build streets that can be walked. If a disease must be watched for life, bring down the price of watching it. None of this puts society in the place of the individual. It puts the individual in a position to act.
Much of what is needed is dull and cheap. Blood pressure can be measured; so can weight and waist size. Tobacco use can be recorded. Walking can be asked about. None of it needs a new hospital. A tape measure at a hospital will not replace a laboratory, but at almost no cost it can raise a flag.
There is an error to avoid. Once we admit that circumstances shape health, it is tempting to say that humans are nothing but their circumstances. They are not. No society can walk for a man, eat his dinner or put him to bed at ten.
The task is not to take choice away, but to make the better choice possible for somebody with a hundred rupees and an hour to spare. Smoking can fall, walking can rise, shops can stock other things, and sugar and pressure can be found sooner. None of it will come from telling people once more to live well. They have heard it, and they will keep hearing it.
What they have not been given is an environment in which the advice can be taken: a street to walk on, a shop that sells something better, a hospital that measures before there is anything to treat, and a price they can meet. Then the word “lifestyle” might be used honestly, because life would be something a man could actually choose.