Public Health Missteps

Public HealthIn what I believe are well meaning efforts to create public health messaging, there have been what I consider some very serious missteps. Though on the face it can seem like a simple concept “Encouraging people to exercise is good because exercise has been shown to lead to better health.”  If we want to increase public health without running roughshod over groups of people who are often ignored or under-represented we have to acknowledge that it is, in fact, much more complicated.

Reader Betsie let me know about a special subway turnstyle in Moscow that accepts 30 squats or lunges in lieu of payment. Another intervention I saw recently are signs at the elevator that say “Burn calories, not energy.  Take the Stairs.”

Many people are excited about these types of interventions, often touting them as a way to prevent or decrease obesity, or help people get more exercise. But at what cost?

I’ll start with the premise that “Do No Harm” should apply to public health messaging, such that efforts to increase public health should, at the very least, not decrease public health.  To me that means that public health messages and interventions don’t create or add to shame, stigma or oppression.

Based on that premise, there are a number of issues with this.  First of all, the suggestion that bodies of a certain size should be prevented or eradicated is seriously problematic.  Telling thin people that they should exercise so that they don’t look like fat people adds to the stigma and shame that fat people already face.  Peter Muennig’s research from Columbia found that most of the health problems that are correlated with obesity are also correlated with being under a high degree of stress for a long period of time (for example, the stress of constant shaming and stigma). Therefore, public health messages that add to the shame and stigma that fat people face may actually decrease health in fat people.

Muennig also found that women who were concerned about their size experienced more physical and mental illness than those who were ok with their size, regardless of their size. So public health messages that make fat people concerned about their body size can also have the opposite of the intended effect.

But it’s more than that.  Because of fatphobia (which anti-obesity messages can create and reinforce,) fat people exercising in public can be subject to shaming.  If they choose not to do public exercise they can be shamed for not exercising.  I notice that people in the Moscow subway station are casually recording people with their cell phones, not to mention the video that we are watching.  As a fat person I often see, and have been personally subjected to, fat people being held up for public shaming for nothing more than existing in public, for exercising in public, and for the assumption that we don’t exercise enough.  This makes situations like the squats and stairs a lose-lose for us.

There’s also the issue of ableism.  When we set up a situation where doing squats or taking the stairs is considered better than paying for a ticket or taking the elevator, we do a disservice to people who can’t do those things.  That includes people who utilize mobility aids like wheelchairs, scooters, and crutches, and it also includes people with invisible disabilities or injuries that make squats or stairs or whatever is being suggested difficult or contraindicated.  Not to mention people who have injuries, congenital issues etc. that make squatting or taking the stairs a bad idea (the form that some of the people in the squat video are using is likely to lead to injury if they do many more squats.)   People with disabilities, including fat people with disabilities, are often subjected to truly atrocious behavior and I think that public health messaging should do everything in its power to avoid making this worse.

There is also the issue of eating disorders.  For people with a propensity for, dealing with, or recovering from, an eating disorder these messages can be very triggering.  Considering the fact that anorexia is the most deadly of all mental illnesses, it seems to me that we’ll want to avoid triggering that if possible.

Reading the comments on articles about these things I see people bring up these issues and get shouted down and told that these groups don’t matter because the messages are good for most people.  I think it’s interesting that they aren’t self-reflective enough to understand how privileged they are to be able to dismiss all of these people experiences and feelings without having any effect on themselves. I also wonder – shouldn’t public health be first and foremost interested in helping those who are the most underrepresented, oppressed, stigmatized and bullied?

Let me be clear that I think most of the people doing public health work (certainly those who I’ve been lucky enough to meet and work with ) are good people, often overworked and underpaid, with excellent intentions.  What I’m talking about here is a paradigm shift and that’s certainly not an easy thing to wrap your head around yet alone do.

I think that a lot of the problem is that members of populations like fat people, people with disabilities, and people dealing with ED are not typically involved in the creation of the public health interventions that are either intended for them, or leave them out completely.   I think a great first step is for people in public health to proactively reach out to those communities, as well as looking for any subconcious biases that they may have that are seeping into heir work.

After that,  I suggest the following:

1.  Make eradicating stigma, shame, and bullying a primary public health goal.  Appreciating our bodies and believing that we are worthy of good care is a much better platform to make decisions for ourselves, and is much easier to do if we don’t have to fight through a ton of shame, stigma and oppression to get there.

2.  Provide options. Work to make sure that everyone has access to the food that they want to eat, and access to safe movement options – that means not just physically safe but also psychologically safe, if everyone isn’t able to go to the pool in a bathing suit without fear of stigma or shaming for example, then we still have work to do. Widely distribute true, neutral, information about the things that people can do to support their health.

3.  Make the message empowerment – acknowledge that, knowing that health is not entirely in our control, how highly we prioritize our health and the path that we take to get there are intensely personal choices.  Empower people to make choices for themselves rather than treating them like they won’t make “the right” choice unless they are shamed or bullied into it.

4. Make the message additive.  Instead of making health about “either/or” or giving things up, create campaigns around the variety of things that we can add to our lives to support our health.  A serving a vegetables or piece of fruit, a little fun movement, a little more sleep, a little less stress,  enjoying our food, appreciating our bodies.

5. Make messaging shame free, blame free, positive, and future oriented (as suggested by research from Yale University.)

6.  Make sure that public health isn’t about making the individual’s health the public’s business, but about making health options available and accessible to the public, including and especially those who are often left out.

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Published in: on November 14, 2013 at 10:56 am  Comments (8)  

8 CommentsLeave a comment

  1. a couple things.

    Is it bad that my first thought when I saw the squats video was that I wish they had those here? Although I admit it’s partly due to the fact that I’m in recovery from ED and things like that often pop into my head. And I’m a broke college student. Which means I’m cheap.

    Also, it’s kind of silly saying “Burn calories, not energy” because, well, calories are energy. Linguistics, people.

    • Re: “calories not energy”, that was my first thought too! Dear English-speaking world, “calorie” is a unit of energy. Your food provides N calories of energy. “calories” are not a substance. …Yeah, I think I’ve already lost this fight.

  2. Mr. Twistie has one of those invisible disabilities: congestive heart failure. Stairs can be hard on his heart, and lunges… just no. He’s already got the world demanding he carry a lot of heavy things because he’s a big, beefy guy and they assume it’s just hunky dory for him to haul that hundred pound item by himself. And he always does it because he feels guilty if he doesn’t. More guilt is the very last thing he needs. It could quite literally kill him.

    Me? I’m fine on stairs, but squatting is really, really hard on my knees and at this point in my life, I’d rather not strain them more than necessary. Weak knees run in my mother’s side of the family and my right one has never been quite the same since I wrenched it tripping over the cat and right down a flight of stairs. It now goes very slightly out of alignment at whimsical moments, which can be quite painful and makes it difficult to walk, let alone squat.

    Plus doing squats when you don’t know the proper technique (and there are quite a few of us – including myself – who don’t) can lead to injury and a complete inability to walk temporarily.

    And let’s not even point out that this money-saving exercise is unavailable to people in wheelchairs and using walkers or canes… and is therefore costing people extra money they may or may not have, and purely because of their physical limitations. Not. Cool.

  3. The squat thing made me immediately think of people who just can’t do them. Basically it is a punishment for people who don’t have that ability.

    Your discussion of ableism reminded me of my friend in a chair whose efforts to join a group for the rights of disabled people was thwarted by the fact that the meeting was held somewhere difficult to get to for anyone disabled.

    Ditching the public shaming would go a long, long way for everyone. What I have been wrapping my head around is the concept that when you judge other people, you are also judging yourself, which is a negative thing. I’d like more people to learn this concept.

  4. *trigger warning*

    I recently relapsed into my ED, these kinds of messages supposedly about health make recovery much, much harder.

    The squat thing would be awesome for my boyfriend, not so much for me. I’ve got one of those invisible illnesses, fibromyalgia and quite possible lupus or RA.

    Health should never, ever be used as a barometer of worthiness. These kinds of public health messages hurt people.

  5. Chevese made just this point in our meeting on Tuesday. It is indeed perplexing (and stupid) that a person who has been shamed into exercising will do so and get shamed for doing it. It’s like the old real estate term NIMBY (Not In My Back Yard) – nobody wants to see THAT happening. Really, really hateful at it’s core. Great post as always!

  6. Suggestion to add a #7 (related to #5): positive modelling of people engaging in healthy behaviors in all sizes. Why do so many of these campaigns to exercise feature models who already appear in shape? I say ‘appear’ because I have no way of knowing their health status. But is that supposed to be inspiring? Or does it suggest that you need to ‘be fit to get fit’? /early morning musings.

  7. I would also suggest that squats-for-pay disempowers people who can’t do squats because they’re carrying things – like, you know, groceries, other supplies, children. Funny, those people tend to be women.

    I want a public health campaign that encourages people to be NICE to each other. Wouldn’t it be fun to dream up that kind of campaign? I’d like to see a wall full of subway ads suggesting that people help each other carry strollers down the stairs, pick up dropped items, and compliment each other on their outfits.


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