Malabundance

Medical and Moral Consequences of Abolishing Hunger

During the recent government shutdown, Americans were startled to learn that some forty to forty-five million people depend on food stamps. Roughly one in eight citizens now receives federal assistance to eat. The revelation provoked alarm in the press, as if this were a sudden crisis. To me, it was no surprise. These are my patients. I see them every day in the emergency department. They are the faces of the Medicaid population, the long-term wards of a system that has replaced work with welfare and self-reliance with dependence.

Most are not disabled. A minority are truly incapable of self-sufficiency, suffering severe intellectual or physical impairment, who can exist only through the charity of others. But the vast majority of welfare recipients I encounter are able-bodied adults of sound mind. They live as they do not because they cannot work, but because our society has made dependence a culture, a learned mode of existence passed from one generation to the next. Welfare is no longer a lifeline; it has become a lifestyle.

The Myth of Hunger

In a decade of emergency medicine, I have seen exactly one case of genuine starvation. He was a young father of roughly thirty-five years of age, whose infant son had died suddenly in his crib. The man’s grief consumed him. He stopped eating altogether. His muscles wasted away, his serum proteins collapsed, and his bone marrow failed to produce blood cells. His illness was pure and tragic starvation, not for lack of money but from total despair. He survived only because others intervened and helped him find the will to live again.

That case stands alone in my career. I have never seen another. Every other “malnourished” patient I have seen has been its opposite. These patients are morbidly obese, insulin-resistant, hypertensive, and swollen with the complications of over-nutrition. In America, the poor are not hungry. The diseases of American poverty are not those of scarcity but of excess. Diabetes, congestive heart failure, sleep apnea, fatty liver disease: these are the hallmarks of the modern welfare class.

Data confirm what physicians observe. The poorer an American is, the more likely he is to be obese.¹ This pattern reverses what one finds in the developing world, where poverty produces thinness and frailty. In the United States, poverty produces obesity and metabolic disease. The explanation is not that poor people “cannot afford” nutritious food, as activists claim. It is that they do not choose it.

Subsidized Pathology

Food stamps were created to prevent hunger, yet in clinical practice they function as a vector of disease. A physician needs only to glance at the diet of the typical recipient to see why. Sugary beverages, refined starches, ultra-processed meats, and cheap fats form the staple diet of subsidized eating. Many patients will spend the first of the month, the day their benefits are loaded, on bulk purchases of soda, chips, and frozen meals. Few buy fresh produce. Almost none cook.

The pathophysiology is predictable. Chronic carbohydrate overload drives persistent hyperinsulinemia. Over time, cells become resistant to insulin’s signal, forcing the pancreas into overdrive. Eventually it fails. Blood sugar rises, vascular endothelium stiffens, and the metabolic syndrome unfolds in full: hypertension, dyslipidemia, and type 2 diabetes. By middle age, many of my Medicaid patients have both legs swollen from heart failure and kidneys already damaged beyond recovery.

Nationwide data show that obesity rates climb as income falls, and that Medicaid recipients are twice as likely as the privately insured to be diabetic.² In the developing world, poverty produces emaciation. In the United States, it produces morbid obesity and eventual metabolic collapse.

I contend that the connection between poverty and obesity is not causal but fraternal. They spring from the same root: the habits and values of the individual. Poverty does not make a man obese, and obesity does not make him poor; both are symptoms of the same disordered relationship to appetite and impulse. There are, of course, those brought low by bad fortune, but chronic poverty, like chronic gluttony, is most often a consequence of character. The welfare state rests on the opposite assumption. It treats poverty as something that happens to a person rather than something he perpetuates, just as it treats obesity as an unlucky condition rather than the result of overindulgence. Food stamps exist on the premise that the poor are hungry victims of circumstance, when in truth many are simply captives of their own appetites. In denying that reality, the state calls vice misfortune and then subsidizes it.

The welfare system treats hunger as a failure of the state rather than of personal responsibility. It imagines citizens as livestock to be fed rather than as moral agents capable of self-government. The result is paradoxical: a population that is both dependent and diseased, both overfed and undernourished. It is not compassion that keeps them there; it is policy.

The Medicalization of Poverty

Emergency physicians are the final custodians of this system. We spend our nights treating the preventable consequences of lives lived without discipline. Every uncontrolled diabetic crisis, every hypertensive emergency, every patient in their thirties on dialysis represents the culmination of years of bad habits underwritten by public subsidy.

When those patients arrive in extremis, we do what our oath demands: we save them. But we also perpetuate the cycle. By rescuing them from the consequences of their choices, we erase the feedback that might prompt change. We write prescriptions for insulin and blood-pressure medication knowing that diet, exercise, and work would be more curative than any pill. We discharge them back into the same environment that produced their illness, an environment designed to shield them from want, consequence, and responsibility.

Much of what I do is not medicine in the classical sense. I treat the pathologies that arise when a society abolishes consequence. Each act may be individually defensible on humanitarian grounds, yet collectively they perpetuate the problem. By rescuing people from the results of their choices, we erase the moral feedback that produces reform, and remove the incentive structures that would otherwise induce many of these patients to live well instead of poorly.

A man who cannot afford to eat must work. A man who cannot work must rely on family, community, or charity. But a man who can always eat, courtesy of an electronic benefits card, need never do either.

Much of what passes for medicine today is not medical at all. In the emergency department, I am as often a social worker as a physician. Patients arrive not with illness but with circumstance. The homeless check in seeking a warm bed and a meal. Others claim “unsafe housing” to secure placement in nursing homes that will shelter them indefinitely. Some come under police escort, choosing the hospital over jail, without any acute medical complaint beyond the misbehavior that brought them there. In each case, I become an instrument through which they can defer the natural consequences of their choices. I am not treating disease; I am providing reprieve from responsibility. The more the system cushions people from consequence, the less they learn from it, and the more firmly they settle into the habits that keep them sick, idle, and dependent.

There is, for me, a personal moral weight in this work. I took an oath to heal, yet I often suspect that my interventions delay rather than deliver true healing. Even when I am acting as a physician rather than a social worker, the same moral tension persists. When I rescue a patient from the consequences of his own choices, I offer temporary reprieve but rob him of the lesson that might have changed his life. The medication I prescribe may save him tonight, but it also enables him to continue the habits that will bring him back to my care next month. I am caught between the duty to preserve life and the knowledge that suffering, in its natural proportion, can be corrective. Medicine has become so preoccupied with relief that it has forgotten that discomfort is often the teacher of reform. In easing every consequence, I sometimes fear I am complicit in the decay of character.

Hunger as Hypothesis

The shutdown offers a natural experiment. Suppose the Supplemental Nutrition Assistance Program were suspended for six months. Would we see starvation? Almost certainly not. What we would see, I suspect, are measurable improvements in public health. Caloric intake would fall. Weight and hemoglobin A1c levels would probably decline. Blood pressures may begin to normalize. Emergency rooms may even see fewer admissions for decompensated heart failure and diabetic ketoacidosis.

Yet such a reprieve is politically impossible. Even the rumor of delayed benefits provoked threats of rioting and looting. The irony is impossible to ignore: those who claim incapacity to work simultaneously boast their ability to commit violence. The same energy required to riot, it seems, would suffice to labor.

Dependence and Dignity

Public assistance in its current form is not compassion. It is a sedative that preserves the body while degrading the soul. It allows a person to survive without demanding that he live well. In the process, it destroys both health and dignity. The physician becomes complicit, treating the medical consequences of a moral disease.

A healthy society must link behavior to consequence. The purpose of charity is restoration, not perpetuation. True compassion helps a man stand on his own, not remain comfortably prostrate. Food stamps, in their present form, do the opposite. They preserve dependence and, paradoxically, worsen health.

Medicine cannot solve this by prescription. We can adjust insulin doses and titrate antihypertensives, but the underlying pathology is cultural, a collective decision to abolish the virtue of self-reliance. A people accustomed to endless provision will not labor, and a body accustomed to endless consumption will not thrive.

The state calls this nourishment. In truth, it is anesthesia. The hunger both literal and spiritual that once compelled men to work has been extinguished, and with it the spirit that once built civilizations. If we wish to restore health, we must first restore consequence. Only when hunger is again possible will dignity—and health—return.

1. Centers for Disease Control and Prevention (CDC). Prevalence of Obesity Among Adults: United States, 2021–2023. NCHS Data Brief No. 508. August 2024. Available at: https://www.cdc.gov/nchs/products/databriefs/db508.htm. Accessed November 2025.

Ogden CL, Lamb MM, Carroll MD, Flegal KM. Obesity and Socioeconomic Status in Adults: United States, 2005–2008. NCHS Data Brief No. 50. Centers for Disease Control and Prevention; 2012. Available at: https://www.cdc.gov/nchs/products/databriefs/db50.htm.
(CDC data show that 42 % of women below 130 % of the poverty threshold were obese, compared with 29 % in the highest income group.)

Ogden CL, Carroll MD, Lawman HG, et al. Prevalence of Obesity Among Adults and Youth: United States, 2011–2014. MMWR 2018;67(6):186–189. Available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6706a3.htm.
(Obesity prevalence among youth aged 2–19 years was 21.9 % in the lowest income group vs 10.9 % in the highest.)

2. Casagrande SS, Cowie CC, Fradkin JE. Prevalence of Diabetes Among Adults by Health Insurance Status and Type, United States, 2012. Prev Chronic Dis. 2018;15:E148. doi:10.5888/pcd15.180148. Available at: https://www.cdc.gov/pcd/issues/2018/18_0148.htm.
(14 % of adults under 65 covered by Medicaid had diabetes, about twice the prevalence of privately insured adults.)

Lipscombe LL, et al. Severity of Diabetes by Insurance Type: Medicaid, Medicare, and Private Insurance. Diabetes Care. 2015;38(7):1415–1422. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4478175/.
(“Severe” diabetes was reported by 10 % of Medicaid patients, compared with 4 % on Medicare and 1 % with private insurance.)