This baffling article by David Leonard about trying to control fatness through punitive measures at the NY Times really drove home to me how much I'm convinced that the issue of what causes obesity---one that gets the bulk of the attention in discussing the topic---is a red herring. Outside of policies designed to make it easier for Americans to eat right and exercise, ideally policies that make eating right and exercising easier than not doing so, I don't really see the value in discourse about individual responsibility. The notion that people are fat because we aren't hard enough on them doesn't gel with reality. In the real world, fat people are subject to so much social disapproval and punishment that it's traumatizing for some. The high levels of punishment for fatness now haven't done a damn thing to reverse the trend of growing waistlines for Americans. You can believe that obesity has no relationship to diet and exercise, or you can believe, as a scientist in this article states, that the law of conservation of matter is the relevant one when talking about weight gain and loss, but everyone in this discussion thinks Americans would do well to eat better and exercise more. And since we've seen that the punitive approach doesn't work, then it's time to shift gears, no matter where you stand on the science issues.

I knew that this article was going to get on my last nerve when it kicked off with the idea that smokers need to be treated not like people suffering from an addiction, but like spoiled children who need to be sent to their room.

Two years ago, the Cleveland Clinic stopped hiring smokers. It was one part of a “wellness initiative” that has won the renowned hospital — which President Obama recently visited — some very nice publicity. The clinic has a farmers’ market on its main campus and has offered smoking-cessation classes for the surrounding community. Refusing to hire smokers may be more hard-nosed than the other parts of the program. But given the social marginalization of smoking, the policy is hardly shocking. All in all, the wellness initiative seems to be a feel-good story.

I don't feel good about it. You know what's not great for someone trying to stop smoking? The stress of being unemployed. But this sort of punitive attitude assumes something that doesn't jibe with reality, which is that smokers are doing what they do because they're proud of themselves for having an unhealthy habit. The only smokers I've known that weren't eager to quit were the ones who just started, and were still trying to convince themselves that they wouldn't get addicted. But smoking is, if I remember correctly, the second most addictive drug there is (after heroin), and so if anyone can lay claim to the fact that their habit is actually a disease, it's smokers. And if you were going to pick an addiction for an employee to have, I'd guess it would be smoking! Most drug addicts see a marked decline in their productivity. All smokers want is occasional smoke breaks. Because you're a smoker doesn't mean you can't administer good health care. No one knows better than a smoker how much it affects your health in the here and now, and they can share that information with patients. I know that one reason I was able to drop the habit before it got too bad for me was that I kept recalling a school teacher I had who got winded after climbing a single set of stairs, even though she was young and skinny and had no other health problems.

But you can see how this attitude of doling out severe economic punishment to smokers is going to translate to obesity policies. In this case, the clinic can't refuse to hire fat people, but they'd dearly like to. That's fucked the fuck up. Again, if you want to reduce obesity rates, look at the facts: Obesity is strongly correlated to poverty. Making more poverty amongst fat people isn't going to help them out in any way, even the way you'd hope, which is by causing them to lose weight.

Then Leonhardt makes a patently false claim:

You can disagree with the doctor — you can even be offended — and still come to see that there is a larger point behind his tough-love approach. The debate over health care reform has so far revolved around how insurers, drug companies, doctors, nurses and government technocrats might be persuaded to change their behavior. And for the sake of the economy and the federal budget, they do need to change their behavior. But there has been far less discussion about how the rest of us might also change our behavior. It’s as if we have little responsibility for our own health. We instead outsource it to something called the health care system.

No discussion about individual responsibility?! The entire discourse around weight and related health issues is centered around individual responsibility. Has he never flipped on a TV and seen all the guilt-inducing diet ads? Sure, liberals like to talk about revising agricultural policies, restricting food advertising to children on TV, and making cities more walkable, and everyone else likes to ignore us in favor of shaking a finger at fat people. There's very little serious discussion about actually rewriting policy in a way that discourages the act of making money by feeding people more calories than they can burn off, especially with cheap food. Thus, I will have to suggest that this myth that we don't have enough punitive approaches to obesity is something that people tell themselves because they enjoy lashing out at fat people.

Like a lot of other bigotries, particularly misogyny (which fatphobia is tied to), I think a lot of the reason people lash out is because they're trying to distract from what they consider their own personal weaknesses. So you see the dreaded Mimi Roth on TV, and you know two things are going to happen: She's going to push hateful, dehumanizing stereotypes about fat people and she's going to talk about food in a way where she embodies the disgust/desire conundrum. The two emotions are strongly linked in most people (think of how, after you gorge yourself on greasy food, or for some, on a sex toy, and after your sated, you immediately want to banish it from your sight), but Roth is almost fun to watch because the two emotions are one and the same in her. Mimi Roth is hungry, and she's going to distract herself by lashing out at some fat people, who she assumes never put themselves through her cleansing ritual of suffering. (When I'm hungry and trying not to eat before dinner, I just chew gum and play Rock Band to distract myself, which probably doesn't pay as well.) She believes in the automatic moral superiority of self-denial, which has yet to work when it comes to sex, so I fail to see why not eating makes you a better person.

I know I sound like a broken record on this, but the morality/disgust approach to public health issues has, so far, never worked, and so introducing it to discussions about diet, weight, and related health issues is likely to follow the pattern of history and fail miserably. Most thinking people finally figured this out with sex. Shaking a finger at people, calling their sexual desires disgusting, and telling them "just say no" hasn't worked at all. People do much better when their desires are validated and brought out of the closet, where we can then have a non-shaming discussion about how to have both what you want sexually and be safe. It turns out that if you present it in this way, people are much more likely to feel positively about individual responsibility. We also needed to address systemic inequalities that make being safe harder to do. People who live in poverty, who have poor access to contraception and education---they subsequently have poorer health outcomes. Only be addressing the pressures on them will we get better results. This model strikes me as the only appropriate one to take when it comes to the issues of food, exercise, and related health issues.