Event: John Frank @ U of T – May 4th, 2017, 12:00pm
Written by: Nicholas Fazio
Room HS106’s full house on Thursday demonstrated the strength of epidemiologist John Frank’s reputation in Toronto’s health-science circles. Over the next hour, he reminded attendees of why this reputation is so deserved.
His talk, which tails the publication of his book, Disease Prevention: A Critical Toolkit, began with an introduction by Dr. Laura Rosella, in which she acknowledged the diverse turnout, comprised of both esteemed public health leaders and Frank’s former students. Then, John Frank, in his stately yet cheerful baritone, embarked on an overview of his theories on chronic disease prevention.
Pellagra and Primordial Causes
The clash between “upstream” and “downstream” treatments of chronic disease acted as the conceptual architecture of Frank’s presentation. He opened with a case study about “pellagra”, a vitamin-deficiency disease that killed more than one-hundred thousand Americans in the early 1900s. As Frank writes in his recent book, “The critical question about the US pellagra outbreak from 1906 to 1940 is why it began then.”
Answers at the time ranged from “it only affects po’ folks” to “it’s just an infection.” It wasn’t until US Public Health Service investigator Joseph Goldberger noticed that institutional staff were never affected, and that the symptoms were non-transferrable, that the culprit was pinned: corn.
The southern-diet staples of “corn-meal, biscuits, fat-belly salt-pork, and molasses” started being produced using degermed corn, which ultimately underdelivered in the vitamin B3 department. This anthropogenic meddling, despite increasing the shelf life of corn products, conjured a lethal combination of diarrhea, dermatitis and dementia for nearly four decades. Localized grindstones, while running the risk of rancid products, proved far less deadly than big-store corn.
Pellagra’s systemic origin (and delayed treatment) exemplify the need for what Frank calls “primordial preventative measures”. That is, treatments at the cultural and environmental level, which affect the whole population—in other words, “upstream” prevention.
A Holistic Approach to Obesity
Frank then theorised that obesity is a contemporary analog to pellagra, in terms of its environmental and cultural causes. The question then becomes one of upstream treatment, which relies on a clear view of what exactly floats upstream—a view we are still piecing together. But why is obesity’s raison d’être so elusive? Why are its driving forces so complexly hidden? The answer, of course, is manifold.
Frank suggests that the relative newness of the obesity epidemic, combined with the globo-economic “elite” whom it most often affects, and its potential relationship to age, smoking and physical labour, all warp the simple dietary explanations.
However, modelling an obesity-antidote after pellagra’s base-consumption model quickly proves futile, as Frank noted, because marketing controls (like taxing categorically unhealthy foods) is all tangled up in international public-trade agreements. Additionally, dominant cuisines and production costs—the main reasons why Mexico imports so much American corn—resist this kind of marketplace dissuasion.
The Patient Problem
Frank’s focus then shifted to scrutinizing current obesity treatment. He mentioned that in Scotland, general practitioners are monetarily incentivized to diagnose obesity. Despite this, it remains difficult for practitioners to enthuse patients about obesity-prevention. As Franks puts it, “they don’t want to take medication their whole life for something without symptoms.”
The other noteworthy issues were, first, the pros and cons of statins vs. dietary modifications, and second, the unlikelihood of a doctor properly conveying environmental obesogen risks to their patients in a hurried 9-minute chat.
Frank concluded by appealing to researchers to investigate the understudied possibilities of primordial or “upstream” prevention.
Seasoned Debaters
Approximately twenty minutes of impassioned Q&A followed Frank’s presentation. Questions regarding the liminal zone between “having a talk” with patients, and general practitioners’ tendency to reduce things to a yes/no answer, produced a heated back-and-forth. So heated, in fact, that one indignant practitioner called the very notion of “having a conversation” out-and-out “risible.”
Similarly, questions about the $3 billion price tag keeping 2.8 million Canadians on statins were raised. As were claims that lifestyle changes are, perhaps, not qualitatively different from other obesity treatments.
One could not help but feel, after absorbing Frank’s carefully assembled presentation, and witnessing the interdisciplinary clash of hypotheses that followed, that this is how the fabric of academia is spun: a public arena, peopled by experts in their field, all gathered patiently, all vibrating with the very real energy of meaningful discourse.
For upcoming events at the DLSPH, keep an eye on our events calendar.