The dangers of imbuing moral danger on health concerns

I hesitated to comment on this whole situation of concern trolls claiming that Regina Benjamin is too fat to be the surgeon general, because while trolling for trolls can be fun, I feel there's a big gap between men who concern troll women's weight in blog comments and anyone who says anything of importance. Or to put it another way, I see commenters pretending to be concerned about a fat woman's health 1,000 times more than I see actual bloggers do so. But I'm not sure where to draw the line on that, and blog comment sections can tell you a lot about what the common wisdom in the general populace is. And as fat activists can tell you, concern trolling about weight is a real common behavior in real life. I should know---when I got a little puffy during college, my then-boyfriend told me I should lose weight, for my health of course, even though I far short of the weight that you need to be in order to be considered overweight. Of course, being far from stupid, I knew that meant, "your size 10 butt is embarrassing to me", and have no doubt that similar statements made online about fat women, or even not-super-skinny women, are in the same vein.

So, with that in mind, what I find interesting about the "OMG HEALTH" concern trolling that comes from a belief that only women can suffer from health problems that correlate to obesity is how much they depend on the moralizing of health that's so damn trendy in our society. By saying this, I'm not making any health claims about weight. That discussion, while interesting, is beside the point of this post. It's enough to know that most people strongly associate health and weight. So when disingenuous sexists start to bellyache about the dangers of letting fat women out in public, they get traction, because it's becoming increasingly acceptable to suggest that not being perfectly healthy is a moral failing that should be punished with social disapproval, shaming, ostracism, and lowered access to society. Of course, we double down on fat people, and triple down on fat women, because of plain old prejudice, but this isn't happening in a vacuum. Smokers, people who don't eat right, and other people with poor health habits are also considered morally inadequate, if harder to judge because they're harder to spot. The fetish for health management is, I suspect, a large reason that the anti-vaccination movement has taken hold. People who want an edge in the moral olympics of prevention are inventing counterintuitive (and anti-intellectual) shit to do in order to win as the bestest, most deserving of good health.

There are many downsides, but one of the most disturbing is that this moral judgment of personal health habits has already started to infect the debate about health care. There's an increasing and unscientific belief that if you have poor health outcomes, it must be because you did something wrong and you don't deserve help. Part of the reason for this is insurance companies and their willingness to deny coverage based on personal habits, and conservatives are pretty open about their fears that health care reform will mean you get the same coverage whether you smoke or eat Twinkies or don't. On top of that, there's an increasing tendency, if you do get sick, to start looking for what you did to deserve it. The problem with this, besides being inhumane, is a lot of people do the same things and get away with it. The direct line between "wrong" behavior like poor nutrition or smoking or lack of exercise and actual punishments isn't real.

It's the problem of conflating statistical likelihood with individual lives. You're far more statistically likely to get lung cancer if you smoke, so you should quit smoking. For insurance companies, this means there's a bottom line reason to exclude smokers from coverage, even if some will never get lung cancer. But providing health care to everyone is a moral issue, and so we try to imbue morality into treating individuals with poor health habits as if they're less deserving, and that's bullshit. If anything ever had a right to go into the "personal flaws with no moral implications" category, then having poor health habits should be it. Instead of using poor health habits as an excuse to shun people that we believe have visible evidence of them, i.e. fat people, we should instead start to think long and hard about having a more generous attitude about the imperfectability of human beings. Same honestly goes for smokers, too. I cringe when I see friends of mine who are addicted to smoking beat themselves up about it. Smoking just happens to be a highly visible bad habit that's been the focus of a lot of public health initiatives, often very good ones that actually end up helping smokers out, since roughly 100% of smokers I know want to quit. But since people make the mistake of conflating attempts to address problems on a large scale for large scale good results with passing judgment on individuals, a lot of smokers sadly have to struggle with feelings of guilt for having what amounts to a bad habit. If all of us were held up to the "no bad habits" standard, we'd all fail.

On the most recent edition of the podcast Pal Cast, PalMD talked about a quackish "philosophy" of medicine that uses the claim of whole person approaches (which all decent doctors use anyway) to exclude people who can't or won't lose weight, quit smoking, or get more exercise. That this sort of idea has any traction at all concerns me, because we should be going in the other direction, trying to find ways to both encourage better health habits and understand that people are not perfectible.

We need more mature, holistic views about these things. Frances Kissling gets at it in this comment:

This country is full of above-average weight women and children struggling for dignity as well as to lose weight. Achieving either of these is not easy. (Never mind that none of these criticisms have mentioned any actual health concerns Benjamin might or might not have, instead presuming "obesity" as a catch-all for bad health.) Having a confident, big-bodied and big-spirited woman as America's family doctor could do more to improve their health than skinny HHS secretary Kathleen Sebelius. It's good to know that even doctors struggle with their weight -- and lead full and active lives in spite of adversity.

Having spent a lot of energy writing about and researching reproductive health issues, I'm really inclined to think that this more flexible, non-moralizing approach actually helps people who are struggling more. By being able to contextualize their issues in ways that don't cause guilt or lowered self-esteem, they feel they have more control over the issue. People who see sex as a fraught, moral issue aren't often in a good place to make healthy changes to their sexual habits. People who don't view the status of your genitals as a judgment on your moral character are often in a lot better position to take care of themselves. For instance, if you get an STD and you think this means that you're being punished for sin, you're much more likely to be in denial, not get treatment, and pass it on. If you think it's got no more moral implications than getting a cold, then you're much more likely to get treatment. Having people come out and speak about getting STDs is very effective in convincing others that having an STD doesn't make you a bad or diseased person, and can help then reduce the STD level. For that reason, I think having role models like Barack Obama share their struggle with quitting smoking will do more to help others quit or not smoke at all, because it reduces the level of moral danger implicit.

Setting aside the debate about the link between weight and health, even if there is a link, it won't be helped by shoving fat people in the closet and pretending they don't exist or that they're morally dangerous. I agree with Frances that it's much more useful, no matter how you look at the issue, to have role models that show that being fat doesn't mean that you're stupid or shameful.