Saying that diabetes is caused by lack of medical attention is stupider than saying headaches are caused by lack of aspirin.
Shocking though it may seem, a non-medical public policy approach to preventing diabetes has been suppressed for over three decades.
It's been easier to see the market forces that foster this disease than to whip up the pressure to legislate and fund diabetes-busting.
That's why the buzz created by the study released last week by doctors Rick Glazier and Gillian Booth of St Michael's Hospital, one of the few hospitals in the world to sponsor a unit specializing in the health impacts of inequality, is so refreshing.
The well-written 223-page report has a title better suited to a doorstopper - Neighbourhood Environments And Resources For Healthy Living: A Focus On Diabetes In Toronto."
But it plops the urgent need to reinvent medicare right onto government policy tables, and raises the possibility of revolutionizing the funding of cash-strapped cities with a kind of medical subsidy for doing the right thing.
By my calculation, the $13.2 billion a year spent on medical care for diabetics - who typically suffer from a lifetime of collateral damage - works out to about $5,500 per typical diabetic per typical year.
An overweight teen with a tendancy toward diabetes who then develops it and lives another 40 years will cost the medical system and taxpayers $220,000 over that lifetime, quite apart from similar costs in lost productivity.
That's an expensive way to subsidize the junk food and auto sectors, the two industries benefiting most from government neglect of healthy policies.
If we apply the principle of avoided cost, the medicare account can well afford to invest cash to prevent one youth in 10 from contracting diabetes. Since we don't know which youth will get the disease, that money is most efficiently spent by investing $21,999 on the supports needed for each one.
Shall we take another look at whether or not we can afford community gardens or bike and walking trails or whether it's smart to spruce up main streets to attract pedestrians? Or whether it's really a free speech issue to allow junk food ads to clutter public spaces?
Nobody spends health dollars as wisely as smart cities. Nobody. So medicare should send cash on down, and save money doing it.
We could even get creative while following this avoided-cost logic. The money spent on diabetes could be better spent financing the transition to a shorter workweek, so there's time for home-cooked meals, or even subsidizing students taking another year to go from Grade 6 to Grade 12 so they can burn some calories instead of the midnight oil doing homework every evening.
Healthy public policy is all about finding non-medical causes of good health and financing them. Get weird and pay teens and tweens an allowance for committing to healthy eating, forswearing junk and exercising every day, even if it means skipping homework. We as well pay them instead of handing over subsidies to the hospital and junk food industries.
The Glazier-Booth study is a milestone in health research because it uses geographic information system computer techniques to literally put the relationship between inequality and illness on the map.
Affluent white people in Toronto do not suffer as high a rate of diabetes as low-income people of colour, a score of maps featured in the study show. A small portion of that difference may be blamed on genetics; South Asians seem to get diabetes even when they're not as obese as typical whites, for example.
But the class and racial divide in disease prevalence is mostly about the kind of neighbourhood people come from, or the ways some people have of getting out of the neighbourhood. Few poor people live as far from a healthy and affordable food outlet or an attractive recreation centre as residents of Rosedale or Forest Hill. But most there have easy locomotion to a gym and a catering alternative to KFC.
By contrast, people who live in the city's northeast and northwest, largely immigrants on low incomes and without transportation, are tied to resources in their community, where they have fewer healthy options and more unhealthy ones.
That's the way the high-fat, high-sugar cookie crumbles, and that's why people who live downtown in less car-dominated 'hoods stay healthier even when they have less money. The "commons" they live in is richer.
Though it made good sense and good cents, "prevent" never got anywhere in the health field for the same reason that "reduce" (as in "reduce, reuse, recycle") never got anywhere in the enviro field. There are fewer commodities associated with prevention to push, and fewer champions to push it.
So instead of following the Zen of public policy, which bases healthy outcomes on non-medical infrastructure, we get the linear approach of free advice on healthy lifestyles to people who lack the means to achieve them.
"Follow the commodity," we might say. Even the sponsor of this study, St. Michael's Hospital, has a Tim Hortons that offers sugar, grease and cream temptations for diabetics who come for treatment, and presumably pays a rental premium to the hospital that a firm selling healthy foods can't match.
That market failure prevents prevention, with huge costs for health and social justice. But there are practical and affordable alternatives that an excellent study has now documented.