How many others missed this early April news gem?  Arizona Governor Janet Brewer proposed socking obese Arizonans who are enrolled in Medicaid or Medicare with a $50 surcharge unless they adopt a supervised weight-loss program prescribed by their doctor.  (Smokers will get nailed as well.). 

Congratulations to the Gov for the world’s first “Fat tax”.   

The Gov’s arguments run pretty simple along the surface:  unhealthy lifestyle choices and behavior eat up the healthcare budget, so let’s make these miscreants and self-indulgers pay.  After all, why should the public subsidize bad behavior?  Looked at differently:  If some guy like me wants to bicycle the streets of London without a helmet, running the lights, why take money away from cancer research to pay for his brain surgery? (It’s a slippery slope:  skiers and joggers are always breaking ankles, and that costs a lot of money, but taxing them would bring us right back to the obesity risk of blogging from the couch all day.).

If the Arizona governor sounds confused on the workings of blame here, as if people choose to be obese the same way our guy chooses to cycle recklessly, it’s because any debate on the merits or not of the fat tax as a public health policy is misplaced.  This is about trimming budgets, not waistlines.  Ha ha. From a health policy standpoint, blaming the sick sounds perverted, though I guiltily admit somewhat less so in light of estimates that the cost of obesity is the US range from $150 to $270 billion.  Isn’t that more than the continental budget for healthcare in Africa?  Anyway, from a financial standpoint, the fat tax is the sort of decision that will be increasingly more common as politicians and health officials scramble to save cash.

 Now flip to HIV/AIDS.  I recently visited MSF’s HIV/AIDS project based in Khayelitsha township, on the outskirts of Cape Town.  It’s an impressive programme, one that has led to a great deal of innovation on the treatment/delivery side of things and, more importantly, to a sizeable scaling up of HIV+ people receiving anti-retroviral therapy.  Depressingly, I found the decade of advances in HIV treatment have been unmatched by advances in preventing transmission.  It’s simple:  too many men refuse to wear condoms and they certainly aren’t interested in abstinence. 

During my visit I listened as young outreach and community education workers exhorted others on the need to do education in the taxi stands and drinking places, or called for opening hours in the evening, etc. etc.  Essentially, the same hopeful exhortations I heard 10 years ago.  As if a “new” or “improved” community messaging will actually produce a sufficient enough change of behavior to reign in this epidemic.  Aside from the fact that it doesn’t work well enough or fast enough in a context like South Africa, I’m still a fan of this sort of health education.  But limits need to be recognized.  The problem isn’t solvable through education because it’s not caused by ignorance.  That is a topic, though, for a later blog.

For now, back to Arizona.  How long before the logic of the fat tax will be applied to men and prostitutes in South Africa?  There, masses of people knowingly engage in high risk behaviour – becoming infected and (quite different from obesity) infecting others – and then fall ill.  They then assert a right to treatment.  So how long before the “no condom tax” or a “surcharge on unprotected sex”?  How long before money is switched out of HIV treatment into other health priorities at the ministry level, as is already happening on the global stage?  In the end, the Arizona fat tax heralds the coming day when budgetary pressure on the state forces a false distinction between “good” sick people and “bad” sick people.  After the obese, after the smokers, will come the reckless, be it the helmetless riders or rubberless fuckers.