Jamie Oliver, ABC's pop Alinsky

Photo: Jamie Oliver in Britain, where he transformed national school lunch policy.


Ms. Dr. Hemodynamics and I were having a little bit of TV time the other night, and Jamie Oliver was trying to convince the lunch ladies of West Virginia that cooking from scratch was a good idea, and railing against some state bureaucrat's affection for chocolate- and strawberry-flavored milk.

Surprisingly, we kept watching.

OK, so, admittedly, I've only seen one episode thus far--but still, I found myself surprisingly compelled by the episode I saw, as a template for health-oriented community organizing.

I have mixed feelings about the moral panic in progress about obesity. The term "obesity" has become so loaded with moral judgment that I've taken to showing people in my clinic the NHLBI BMI calculator while holding my hand over the category labels. I always explain that this is a continuum, and that it's my view that the terms "overweight" and "obese" are better understood as "higher risk" (for 25 to 29.9) and "even higher risk" (for over 30). I don't think that calling someone "obese" is that useful. And absolute weight numbers, especially around the high 20s/low 30s fairly "overweight"/slightly "obese" range that so many of my patients and I occupy, may be at least as important as proxies for other things--like cardiovascular fitness and nutrition--as problems in and of themselves.

But my own struggles with weight and fitness, and those of my patients, are for a different day. The genius of Jamie Oliver's show, at least the episode I saw, is that he doesn't waste a lot of time trying to persuade individuals to change their individual diets. He knows that they'll drink the chocolate milk if it's in front of them and they have a choice between that and regular milk. Who wouldn't? And if the chocolate milk isn't there, they won't drink it, because how would they?

Here are some other aspects of why Jamie Oliver showed himself to be a smart community organizer in the 45 minutes I watched him:

1. Big change comes from changing big systems. He knows that the leverage is in the structural intervention. Children in this town all eat lunch at school, so don't try to get them to bring their lunches. Change the school lunches. People at a work place eat food that's close to work, so don't ask them to drive to some place that has a salad bar two miles away: drive a food truck that serves salads and bison burgers up to the work place. Like smoking, a lot of food choices are made because of availability, proximity, habit--all things that can be affected by altering the physical and economic environment at least as easily as changing individual minds.

2. Individual beliefs matter. Conversely, he knows that structural interventions can only work if a large enough number of individuals support them. People who think eating better food and avoiding obesity is a good idea will appreciate the support that a structural intervention gives their personal goals. But if people don't understand the rationale behind the changes, they'll just be mad that there's no chocolate milk or french fries--they'll register a change, understand it as out of their control and leading to a result they don't like, and demand a change back to the old system.

3. Every individual matters. Anyone at any point in the process, from state bureaucrat to food supplier to principal to cook to teacher, can either advance or sabotage a project for change. Because of this, he also lets everyone know that when they are supporting change, they are instrumental in doing so. He lavishes praise on the smallest change. "Fantastic!" he raves, as if the low-level administrator who removes the chocolate milk for a day should win a MacArthur "genius" award. Even non-committal shine-on answers get a "great, great" from Jamie, as long as they're not frankly obstructive--though he doesn't take "maybe" for an answer, and goes back to trying to close the deal.

4. Follow the money. He understands that the approach he's recommending will cost more. He targets the town's biggest employer, which nicely is a hospital. He shows that they should have an interest in supporting his changes and relentlessly hits them up for money. (That in fact they may not have any particular economic interest in the changes he proposes is a sign of the utter perversity of the healthcare system, but that's another reality TV show.)


These four ideas are the basis for a lot of successful community organizing.

I'm not sure Jamie Oliver has got it all figured it out--most importantly, I'm not seeing him build a corps of organizers who will stick around to keep the pressure on. But maybe at the end of the show, the real point is not the people in that particular town--but the corps of organizers he might build from the millions of people who are watching him on Friday nights.

Our farmer

A member of our CSA, on our farm's Facebook page, laying out a week's small share on the counter, and sharing the photo with the world.

Today was the last day of the year to pick up produce from our farmer. Our farmer is an old punk rocker, now a single dad and farmer. His son (who is maybe 6?) was enthusiastically shilling the hen-of-the-woods mushrooms that our farmer was selling as an extra if we wanted to add it to our regular farm share: "It's fifteen dollars! You have to buy them!" No thank you, I said, bemused.

This last couple of pick-ups are extras beyond what we originally expected. We'd negotiated which of our two-out-of-three bonus sessions we'd attend, because we're going off on vacation soon, and getting married. He remembered this, and cut me off a hunk of hen-of-the-woods mushroom and said, "You're getting married, right?" Yep. "It's a gift." His son, still in salesman mode, shouted, "Fifteen dollars!" No, our farmer told him, it's a gift.

Our farmer has been frustrated and disappointed all season. Earlier this summer, the weather was so lousy that even our NPR station had started doing lengthy stories about the fact that it was raining; and we heard him on the radio talking about how the rainy weather had flooded out his corn. That was how we knew we were able to prepare ourselves for the disappointment of not getting any corn from our farmer later in the summer. We did get lots of good greens, though, and turnips, and radishes, and green beans, and cilantro, and kale, and some green tomatoes and some red ones. It was a tough year for our farmer. He was a little bitter, a little sad-seeming, and a lot apologetic at the end of the season.

But we were happy. It was our first season with a community supported agriculture program, and although it was apparently a bad year for our farmer, it made a tough summer a little sweeter to go get our produce from our farmer every week. Every Thursday we'd go to a corner about six blocks from our house, where he'd have a truck pulled into someone's driveway, handing out produce, often with some other guy who looked like he was probably an old punk rocker too. (Old punk rockers don't wear punk clothes any more. I'm not sure why old punk rockers look like they were once punk rockers, but there's a look. I think there are a lot of people in Narcotics Anonymous who look like that.)

"Large or small?" he'd ask when we approached--the two categories of shares. We had a small share for the two of us, so we'd hear instructions something like "One each of each of these, then a pound of the beans, and three peppers." We'd fill one of those reusable grocery bags with our loot for the week, and come home and have farm dinner--this year, very often roasted root vegetables and a salad, and then from the big store, maybe some turkey sausage or some chicken. Everything tasted great, and it was pleasing too: it was from our farmer.

There is no particular reason that all kinds of people couldn't have a farmer. Back in my hometown in California, there were Hmong families taking spots of empty land in poor neighborhoods, and farming the hell out of those little spots, suddenly bursting with green. They fed their own families, I'm sure; but with just a bit more land--knock down a couple foreclosed homes that aren't getting sold, till the land, and make a neighborhood farm--you could imagine these folks becoming neighborhood farmers, so that people would amble down the street and pick up the week's produce from their farmer.

I know from my dad--who's spent his life thinking about stuff like this, and in many ways dreaming of the day that ordinary people would be talking about going to their farmer like they talk about going to their doctor or their hair cutter--that there are all kinds of reasons this is harder than it sounds. Still, I'm kind of incredulous and pleased that by paying a sum up front that is almost certainly less than what we spent on produce last year over the same amount of time, we got great produce every week, from an old punk rocker who we can call our farmer.

Our farmer: there is something about these kinds of relationships that is different than the more fragmented retail marketplace, something that is important and good. It is how I want people to feel about having me as their doctor; I want them to see me in good times and bad. And even when they see that I'm frustrated with the insurance system, or apologetic that I'm running late, I want them to feel that I am their doctor, like I feel that my farmer is my farmer; and to feel like, at the end of the summer, they got a decent deal even in a bum year.

Hospitals and farmer's markets

Should every medical center have a farmer's market?

This is the brilliant idea of a Kaiser Permanente physician in Northern California, who has convinced Kaiser to host farmer's markets at many of its medical centers.