Sweet Danger - Jeff Ritterman
Jeff Ritterman, cardiologist and board member of the San Francisco Bay Area chapter of Physicians for Social Responsibility working to combat medical racism and climate change, discusses his experience and lessons learned from proposing the first municipal soda tax in Richmond in 2012 and his work on the tax in his time serving on Richmond's City Council. Though the 2012 measure did not pass, it would be followed by successful sugar sweetened beverage tax efforts in other parts of the Bay Area, including Berkeley and San Francisco. Jeff highlights the importance of collaborating with and centering Black and Latinx community members who carry the disproportionate health burdens caused by the beverage industry's predatory marketing of sugary drinks and uplifts other measures, such as removing sugary beverages from health centers, to decrease sugary drink consumption. He breaks down some of the literature on the mechanisms by which excess sugar in sweetened beverages lead to diabetes and cardiovascular disease, as well as touches on the ways the beverage industry contributes to poor health and environmental outcomes in its production and distribution.
This episode of In Praxis is a part of Season 2: Sugar Sweetened Beverage Taxes. Learn more about Praxis’ work around SSB taxes on our Centering Community & Equity Through Sugary Drink Tax Investments page.
The information, opinions, views, and conclusions proposed in this episode are those of our podcast guests.
You can also tune into this episode on Anchor, Spotify, Apple Podcasts, Google Podcasts, and Stitcher. Below is a transcript of the episode, edited for readability. You can also watch this episode on YouTube with subtitles for accessibility.
Sweet Danger – Jeff Ritterman
Podcast Transcript
Who's going to volunteer in the church or the temple or the synagogue? Who's going to volunteer to bring a meal to the neighbor who's blind or who's shut in? It's not going to be the person with diabetes or who just had a heart attack, so as we make our communities healthier, we raise the standard of living, the standard of happiness for everybody.
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[In Praxis Intro] You are listening to In Praxis, a podcast by The Praxis Project created to support, hear from, and uplift the stories coming out of the ecosystem of basebuilding organizing. An ecosystem that includes frontline basebuilding groups and the folks who help support their important work. In this season of In Praxis, our hosts, Julian Johnson and Kourtney Nham, focus on sugar sweetened beverage taxes. We have compiled interviews from advocates working on issues surrounding the reduction of sweet and sugary beverages as well as the taxation of these products. Participants of this podcast are community members, public health practitioners, health department representatives, and concerned parents that span across the country. In each episode, you will hear about their phenomenal work as well as their perspective on the health effects of sugary consumption, and in what ways policy can be used to combat this and lead to reinvestment in our communities.
Kourtney Nham: Just as an introduction, I'm Kourtney, I'm one of the Health Justice Interns at Praxis and I’m here with Jeff Ritterman today. Jeff, do you mind introducing yourself and telling us a little bit about yourself to get us started?
Jeff Ritterman: Yes, hi, I’m Jeff Ritterman. I'm a cardiologist and an internist, and when I was on the Richmond City Council I proposed the first municipal soda tax which unfortunately did not pass, but soda tax history since then has been largely positive. I did get a chance to go down and help in Mexico before their vote and a little bit in Berkeley which was, of course, historic and wonderful for us out here in the Bay Area, so that's what I've been doing around the soda tax. I also work with Physicians for Social Responsibility and right now we're working primarily on combating racism in health care and in medicine.
Kourtney Nham: Thank you! I know you touched on this a little bit but how did you first get involved in working on issues of health?
Jeff Ritterman: Well, I’m a doctor, so I see the world through the health lens. I've always seen it through the health lens and part of the reason I went into cardiology was because I had this feeling that heart attacks, coronary artery disease–the major killer in our country–is related to stress and the way we've organized society. I think if we change the social conditions and improve them for people, we'd all live longer healthier lives. Of course, that came crashing in on me with the sugar sweetened beverages that are promoting all this disease, so it was a natural leap to see if we could do something about that and improve it as a public health problem.
Kourtney Nham: Is there anything in particular that made you decide to invest your energy specifically in soda taxes and reducing sugary drink consumption?
Jeff Ritterman: Well, yes, at the time Wendel Brunner was the Contra Costa County Public Health Director, and he and I were working together on a number of public health projects and when we got the statistics on our school age children it was clear that we had a terrible obesity problem and that it was racialized. It was a lot in minority children, and if that trend was going to continue, we were going to have just an enormous problem, public health problem, in our City of Richmond. The more people that are obese, the fewer people we have to participate in voluntary organizations, more people need care and treatment, more people become disabled. It seemed obvious that what we needed to do was some major intervention which would stem this tide of diabetes, obesity, and it's also connected to hypertension, coronary disease, stroke, amputations, fatty liver, even some cancers, so we have a public health emergency, and we need to address it.
Kourtney Nham: You mentioned that you were involved in the municipal tax for Richmond for soda taxes, is that the first activity you remember doing that involved sugary drink consumption and its health effects or have you been involved in anything else?
Jeff Ritterman. I joined the city council, I ran for election and was elected to the city council with the idea that I could try to take public health science, public health data and use it to make municipal policy. One of the first things we did was around smoking because we were told by American Lung Association that we had a D grade or maybe even an F on our smoking policy in Richmond, and so I worked on that with other members of the council, the current mayor, Tom Butt. After we passed our new anti-smoking ordinances, we became a model for the state because we passed very strict ordinances, so that was really a win for us public health-wise. The science said that if we did that we were going to save lives, and then the next thing we tried was the soda tax. There's another big issue in public health which is income and wealth inequality which results in terrible public health statistics, and we introduced that issue in city council, but it's very hard to figure out how to do municipal policy that improves that, but that's another area that needs huge attention in this country. We have to begin to make this a more level playing field and bring up those who don't have enough and maybe we even have to take away a little from those who have way too much because it's better for everyone if we're more equal and there's nobody that doesn't have enough to eat or drink or a roof over their heads. So that’s another huge issue, along with the sugar sweetened beverages–but sugar sweetened beverages is right there! It's something every community could do right now, it's easy to address, the data is clear, so we really should have a national soda tax, then that money should go into preventing and treating diabetes and these awful illnesses that the sugar sweetened beverages promote, and I think just like the tobacco industry was really the target in the past, the soda industry is a target now. They are making billions of dollars on a product that is not safe.
Kourtney Nham: Yeah definitely, I totally agree with you. Yeah, and I know you've touched on this a little bit in terms of like your work that you've done to reduce sugary drink consumption especially with regards to the tax, I'm wondering if like there are any other strategies you've used to reduce sugary drink consumption–like education campaigns, research, those sorts of things?
Jeff Ritterman: Well, I think there's some low-hanging fruit that I'm trying to go after, and we still need to go after. All of our medical centers–I worked at Kaiser and I worked at LifeLong–why not prohibit sugar sweetened beverages in all of our medical centers? We don't sell alcohol and we don't sell cigarettes in our medical centers, why should we have to sell sugar sweetened beverages or other unhealthy food offerings? So, that's something sweeping that could do very easily. You get Kaiser and UCSF and a few other big institutions to agree, and you can move all of that out, so there is some kinds of low-hanging fruit that we can go after. Another place is we really have to work on the education in the schools. We need to figure out ways to really promote drinking water, tap water. You know, some schools have done this. Some schools have had competitions for making the best water bottle or doing a video promoting healthy beverage choices, so there's a lot we can do with that sort of thing in our education system and can go all the way up through higher education. We need our college students to understand this, we need our college students to be ambassadors in our community going around and explaining to people, but it's very difficult because... We could prevent cigarettes from being sold near schools, but we've not yet prevented sugar sweetened beverages from being sold near schools. If you put yourself in the shoes of somebody who is running the convenience store, they're often somebody who's from our community who's struggling to make ends meet, and unfortunately their livelihood is dependent on junk food. You know, and it's not easy to convert those convenience stores into something making healthy offerings, and all of these convenience stores were really started–if you look back at the history–as basically outlets to sell junk food and that's what they were started for. They're kind of like the junk food drug dealer in your neighborhood.
Kourtney Nham: You know, that's an interesting point. I never thought about how medical centers sell sugary drinks even though we know that they're so awful for health, so thanks for sharing that. I'm wondering because I know you've touched on this a bunch; in your prior answers you've mentioned a bit about how there's racial inequities and socioeconomic inequities that come into play when we're talking about sugary drink consumption. I was wondering if you had some ways that health equity can be centered in soda tax policy and if any of those ways you think are particularly effective?
Jeff Ritterman: Well, I have to say in our own experience in Richmond I wish I had it to do over again because I would have made a lot greater effort to appeal to the African American and Latinx communities. I think we lost in part because the African Americans on the city council and in the community came out strongly against us. I really blame myself for not understanding that I needed to make more of an effort and that we needed to find places for common ground, and unfortunately the soda tax came at the same time as a city council election, so it tended to polarize people based on who they wanted elect for city council not looking at it as a public health problem. That's the negative side, on the positive side you saw how Mexico made great strides and they've had wonderful public health commercials and so on which have really dramatized it for the people. They've done public demonstrations where they've brought out diabetics with amputations to show just how horrendous this can be, so I think we can learn a lot from others. The Berkeley campaign was really a wonderful, successful campaign. We've got that big blow up–what's it called–Canzilla, a big soda can that you inflate. You know what, we need to keep getting the message out over and over and over and over again and not stop because the big soda companies are getting their message out over and over and over again. They've convinced us that Coca-Cola is the same as sex appeal and happiness, but it really rots your teeth and gives you diabetes and ends your life young, and we need to get that message out. The more we get that message out, the more people will understand, and the healthier our society will be, and we can defeat them! We really went a long way to defeating big tobacco, we can defeat big soda. People shouldn't despair. They don't have much to stand on, their product is not healthy period.
Kourtney Nham: Yeah, and I think that actually carries us perfectly into my next question. So, as you were talking about the beverage industry has a really aggressive and persistent tactics in the way that they resist policies that might limit their sales, especially when it comes to soda taxes. As you talked about a little bit, the industry comes out really strong with a lot of messaging that really bolsters their side and one of their go-to's is arguments around regressivity, this idea that soda tax will hurt people with lower incomes. I'm wondering if you have any good counter–messaging to this industry staple and what is a good counter message that really centers health equity?
Jeff Ritterman: Well, let's look at our health statistics in the country and let's look at the rise of diabetes and the rise of obesity–and even in the medical world people talk about a “diabesity” epidemic, and they use the word epidemic. We have something that has swept the country and people are dying and people are losing limbs, and diabetes is not an easy illness to live with. You’re testing your sugar several times a day, so you're pricking your finger, you're worried about everything you're eating and drinking, you're taking medicines and the medicines are sometimes even too expensive for people, and it's cutting your life short, giving you a heart attack or a stroke or loss of a limb, sending you to dialysis–so the reality is frightening, and the reality is horrible. And these drinks are totally connected with that reality, there's no doubt about that now, so the question is: How do we help people understand that? And how do we get that message across particularly to those most vulnerable–our children and those in low-income communities and those in communities of color? We have so many heroes from those communities. Could we get Steph Curry to say, “I drink water”? Steph Curry says, “I drink water, I don't drink soft drinks,” tomorrow half a million people give up soft drinks. We need to keep working with all those in our communities who have a lot of influence. I can say whatever I say and it's not going to change what half a million people do tomorrow, and these celebrities are often the same ones who are asked to be in the soft drink commercial. What if Lebron James didn't do the soft drink commercial? What if he did work with those snowboarders who have a campaign Drink Water? What if he did that? So, I think it's only a matter of time… Doctors used to do commercials for cigarettes. You don't see that anymore, so we can change our behaviors, we do change our behaviors, and this is going to be one that we are going to change over time, and eventually the balance is going to shift in terms of health because nobody wants diabetes. We're going to win this one too, but we have to keep working. We have to work hard, and we have to be persistent, and we need young people. I'm going to be 72 this month, we need young people to fill in and take the lead in this because young people are the future.
Kourtney Nham: I guess going off of that a bit, another thing that the beverage industry really likes to do is refute existing research and evidence against sugary drinks. They make a lot of claims about how sugary drinks are the wrong target, and on the advocate side what usually ends up happening is that they have to present really robust research showing why the beverage industry is incorrect. I'm wondering if you have in mind like what is the most pressing research need that advocates should advance in the efforts to oppose industry claims?
Jeff Ritterman: Well, there's research on a couple of different levels. There's the public health research which is looking at big populations and a lot of it's been done by the Harvard School of Public Health with a big study in nurses or a big study in health professionals. All those studies over multiple years show that the addition of one sugar-sweetened beverage a week results in a significant increase in heart attacks and strokes. So, there's the epidemiologic literature which doesn't prove causality, which shows an association. It shows that the more sugar-sweetened beverages a person drinks–white or Black, young or old, male or female–the more you drink, the increased risk in diabetes, heart attack, stroke, fatty liver. That's an association. Then we know that if we put people in a metabolic unit where they live for a week or two, and we alter what their drink is we can prove that when we give people a drink with a lot of sugar in it, in a very short time they get fat deposited in their liver, and this is actually how it starts.
I was a cardiologist for 30 years, I never asked myself where is fructose metabolized? Fructose is metabolized in the liver, so as soon as you drink something, there's a big vein, the portal vein, takes that sugar from the intestine right to the liver, no digestion. The liver can't deal with the amount of sugar, so it converts it to fat, and the fat gets deposited in the liver, and the liver then becomes resistant to the hormone insulin. The pancreas realizes the liver is not listening, so it works harder, it makes more insulin. It eventually poops out from overwork, and that's where the diabetes comes from. We have a clear line; we know now how it works. You drink the sugar, it goes to the liver, the liver makes fat, the fatty liver becomes insulin resistant, the pancreas overworks, and it fails, and you get diabetes. But that liver that makes fat, that fat also goes out into the bloodstream and it makes you vulnerable to heart attacks and strokes as well, so we know how it works. We can prove that if we give you sugar sweetened beverages for a week that your liver which wasn't fatty, now is. We can produce the pathology, and we can reverse the pathology by taking away the sugar sweetened beverages, so we know how it works. Just like cigarettes, we know how it works, so it's not a mystery. Our body isn't going to change; our liver isn't going to be able to handle these huge amounts of sugar that we're giving it, it's not going to evolve into a different liver, so the only logical thing to do is not to give the liver so much fat to deal with. And that's easy, take away your sugar sweetened beverage and drink a glass of water. It's really easy. You know, suppose we had this problem. We could say, “oh my god, people are dying because they're drinking these cans of sugar sweetened beverages.” I have an idea, let's pump safe drinking water into every house, and people can just open the tap and they won't have to buy that sugary stuff. Well, we already have the infrastructure; we have clean drinking water in every household. If you don't think it's clean enough for you, get a filter, but right now we can combat it, we can reverse it, and your children won't get diabetes. It's a good deal for you.
Kourtney Nham: Thank you, I know there’s like already a wealth of research out there on this, so this is great to hear your insight. I'm also a little curious–this is a bit off script–but I’m wondering if like you could redo the tax in Richmond again, what would you do differently and do you have any lessons learned? Are there other ways you would involve and center, you know, the people who are most vulnerable to the effects of sugary beverages and the industry? Yeah, I don't know if you have any insight on that.
Jeff Ritterman: Well, I would make it a general tax, all it needed was 50 percent to win which we did, but we had an accompanying measure because we were afraid people wouldn't understand that we were going to use it for health, but I dropped that. I’d just make it a general tax. I would spend a lot more time with the African American community and the Latinx community. I would work with…there's an African American newspaper that has big circulation in Richmond, I would work with them and see if I could get them to understand better, and I would try to get the members of the health care community who are African American and Latinx to work with me more closely. I didn't really do that. I don't know if we would still be successful but there were a lot of lessons learned from this. I would approach it somewhat differently, but it’s really: learn from your mistakes; be persistent; if the science is on your side, keep working, keep working, keep working; don't give up. Get other people passionate about it. You know, gee, maybe somebody lost their father or their grandfather to diabetes. See if you can enlist that person, see if you can get them to help more.
Also, I wasn't really schooled in running campaigns. Larry Tramutola– I’m probably mispronouncing his name–helped a lot in the Berkeley campaign. So, there really are people around who understand campaigns as a science and do this as their livelihood, and I would try to get some of those professionals more involved. Now when you get them involved it also means you got to raise money to pay them, so it's another issue, but I think we learned a lot of lessons and keep working. If you’re on the right side, keep working. We didn't get the cigarette taxes right away, we didn't end apartheid right away, we didn't get rid of Pinochet right away, you have to keep working and working and working. We still haven't gotten rid of nuclear weapons, and we have to do that. There's a lot on our plate of what we need to do in addition to this, but the lesson I've learned is don't stop, enlist other people, get young people involved–they're going to be involved for a long time. Their lives are affected more than yours, you don't have so much time left; they have their whole lives in front of them.
You know, it's not only that sugar sweetened beverages kill you with diabetes and heart attacks, they waste an enormous amount of fresh water. The aluminum and the glass is enormously polluting. There have been big lawsuits in India against sugar sweetened beverage companies because of them draining the water and the farmers don't have water to water their crops, so it's not just one thing. How many Coca-Cola, Pepsi cola trucks are burning fossil fuel to move the stuff around, when all you have to do is open your tap and you have something healthy? You don't have to do that. It’s an enormous industry that's peddling something that's unhealthy–and it also tells you the challenge. Where are you're going to find jobs for those truck drivers? Where are you're going to find jobs for those people who mine the aluminum ore? These are big changes we have to make to turn this ship around. It's not easy, it's not going to be easy, but you know it's just like with fossil fuel. It's killing us, it's killing the planet. We have to turn the ship around.
Kourtney Nham: Thank you for that. That was very inspiring, and I like how you kind of touched on the multiple things that have to be taken into consideration, and I think that actually goes really well into the next and final question before I ask if you have anything else you'd like to add. I’m wondering what will it look like when advocates win? For you, what is endgame and like what is the ideal outcome from this work?
Jeff Ritterman: You know, the ideal outcome is that we get rid of obesity, we get rid of fatty liver, we get rid of type 2 diabetes–we're not going to get rid of type 1 diabetes this way but we can get rid of or certainly cut way down on type 2 diabetes. So, imagine a city like Richmond where all of a sudden, the population is considerably healthier. Who's gonna coach little league? The diabetic guy who can't walk and is looking to a possible amputation or the healthy guy who can't wait to play with kids? Who's going to volunteer in the church or the temple or the synagogue? Who's going to volunteer to bring a meal to the neighbor who's blind or who's shut in? It's not going to be the person with diabetes or who just had a heart attack, so as we make our communities healthier, we raise the standard of living, the standard of happiness for everybody. Everybody feels better when we're healthier. Fewer of us have to worry about the neighbor next door who just had an amputation. That’s how it looks in the future. We'll go into an elementary school, and instead of half the kids being overweight, five percent of the kids will be overweight, and we'll know that we can concentrate on them, and we can work with them to make them healthier. It's very hard to do when 30 to 50 percent of the kids are overweight, and when they're going home and they're getting Coca-Cola. So, we're going to see just a totally different feel to our communities. It's going to feel healthy to be in your community. You're going to see people out doing healthy things, and it's going to inspire you to be healthier. We're going to live longer, healthier lives, and we're going to be nicer to each other.
Kourtney Nham: Thank you so much. Well, that was it for my questions, I'm wondering if you have anything else that you'd like to add, if there's anything you feel that this interview didn't cover.
Jeff Ritterman: Well, I just want to thank you, and this is exactly the kind of activity that I'm talking about where we need to be persistent. You know, you're going to help get my voice and a lot of other people's voices out. It's going to reach somebody, I want that person, if it reaches you, for you to reach out to other people. Let's make our world a healthier world. Right now, we're dealing with a world where we're feeling that there's more problems than we can deal with, it's depressing us, it's making us unhappy, and we're not treating each other as nicely as we could. Let's live a healthier life. Let's take this message and bring it to the people in your community. Let's be kinder and love each other more, that's what we can do. Think of how great it would be if we're healthy, we're caring for each other, we're not jealous of one another because we all have enough, we get our greatest satisfaction by being in our neighborhood with our community. That's what we need to build, so if this voice–my voice–reaches you, you go out and talk to five more people and ask them to talk to five more people. Let's build the world we want. We can do it; we can only do it if we all work together.
Kourtney Nham: Yeah, this podcast we're definitely hoping to share with a lot more people and hopefully reach more communities that way, but thank you so much for your time!
Jeff Ritterman: Oh, it's an honor. I’m really so touched that you thought to get in touch with me and thank you so much.
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[In Praxis outro] Thank you for listening to this episode of In Praxis. We hope you all enjoyed it. Make sure to visit our website, www.thepraxisproject.org, where you can check out additional episodes of other guests as well as learn more about our work.
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