In the previous post
I mentioned a few different commonly proposed public health strategies, and how
most of them fit quite nicely into the political spectrum characterised by an
authoritarian-libertarian axis and a left-right axis. In this post I’ll discuss the rationale and
efficacy of the strategies of blaming and shaming, which I thought both fit
nicely into the authoritarian right quadrant.
This is because of the emphasis on personal responsibility in these
strategies, which is a key value of the political right, and because of the
authoritarian nature of blaming and shaming others*
The strategies of blaming and shaming are ones I thought
of later, after I noticed that none of the strategies that initially came to
mind fit nicely into the authoritarian right quadrant. I think this is due to blaming and shaming
not really being that commonly discussed as public health strategies, probably
because so many people find it abhorrent, and also because I haven’t been the
recipient of either, as they are generally just applied to people who are
overweight and obese
It’s worth noting that blaming and shaming are so rarely
applied to other health conditions largely caused by poor diet and lifestyle
and so rarely applied to unhealthy behaviours when the individual is not
overweight or obese. Blaming and shaming
may be quite specific to overweight and obesity because it is visible unlike other
costly chronic diseases, it’s easier to jump to the conclusion of a character
defect (gluttony and sloth) and perhaps because it triggers something in our
brains like a sense of unfairness (they are having more than their fair share)
Even though I bundled blaming and shaming together they
are actually two different strategies both with slightly different rationales
and outcomes
* However, this doesn’t mean that blaming and shaming
others are strategies that are exclusive to the authoritarian right. In fact,
these days I see shaming being more commonly used by the authoritarian left
(social justice warriors)
Rationale of blaming
The rationale of blaming is that individuals are
ultimately responsible for their behaviour, and consequently responsible for
their health status. That holding other
individuals responsible for their health behaviours and health status is both a
statement of fact and more likely to result in behaviour change and health
improvements than not taking personal responsibility for their health
behaviours and health status
However, there are many factors beyond an individual’s
control that can strongly influence their health behaviours and health status:
·
To start from the beginning, individuals cannot
be held responsible for the genes they inherit, and the particular set of genes
can strongly influence behaviour and health outcomes. Genetics are a strong predictor of obesity
for example [1]*
·
Next is that the health status of the parents at
conception, the health status of the mother during pregnancy and breastfeeding,
and the child’s environment during the early years all strongly influence an
individual’s health later in life. In
fact there is a whole field of study called the developmental origins of health
and disease (DOHAD) [2]
·
And finally is the environment the individual is
in, including the influences from the family, factors that go with socioeconomic
status, obesogens, etc (see this map of factors behind
the obesity epidemic)
In fact, when you think about it, our behaviour and
thoughts are entirely due to our genes and environment, both of which we
ultimately have no control over, and thus free will cannot exist (a little more
on this later). This all begs the
question of whether it is appropriate to blame someone for their behaviours and
health status, or whether these things are merely a product of circumstances
that are ultimately beyond an individual’s control
* Although the extremely low prevalence of obesity and
other chronic diseases in western populations 100 years ago and in hunter
gatherers and other non-industrialised societies indicates that it’s extremely
rare for genetics to be a sufficient cause of chronic disease
Efficacy of
blaming
Since the strategy of blaming is like a soft form of
shaming and has an appeal to personal responsibility, the efficacy of blaming
is related to both of those strategies and so should be covered when discussing
the efficacy of those strategies.
Rationale of
shaming
The rationale of the strategy of shaming has two
components that are outlined well in this paper [3]:
·
Individuals are not sufficiently aware of their
poor health behaviours and poor health status or are not sufficiently aware
that their poor health status
·
‘Soft’ public health strategies, like self-regulation
of the food industry and education, haven’t worked and so ‘hard’ public health
strategies, like taxation, bans and social coercion (such as shaming) are
necessary to improve health and reduce healthcare costs
Both the rationales of shaming depend on other people
being negatively affected by someone else’s health status, and consequently
their health behaviours. This is
generally because of the costs imposed on the public health systems, but could
also similarly develop if an individual’s poor health was negatively affecting
a company’s productivity or the productivity of a country, particularly if that
country is very collectivist or is being economically or militarily threatened. Without such conditions, resorting to such
antagonistic measures as shaming is probably just a bullying tactic
The rationales of shaming are actually fairly reasonable:
·
85% of Australians said they were in good or
excellent health despite most being overweight or obese, half having a chronic
disease, many being on prescriptions and very few meeting targets for diet and
exercise [4]
·
‘Soft’ public health strategies evidently aren’t
working
* Given that shaming largely depends on someone’s poor
health choices and health status leading to costs on others, it is more
difficult to justify shaming someone who pays a large amount of tax (being a
net benefit to the public health system) or is a net benefit to society in
other ways
Efficacy of
shaming
Without looking into this too deeply myself, there seems
to be a fair bit of evidence that fat shaming and body fat stigma on average doesn’t
work and has the opposite effect (more calories eaten and more weight gain over
time) [5].
This is not too surprising as someone
who is overweight or obese is quite aware of that fact, and is reminded of it many
times daily without the need for other people to point it out, and that intrinsic
motivation works better than extrinsic motivation
Of course, some people can credit fat shaming for at
least part of the motivation that started them on successful long-term weight
loss. In addition, if shaming was done
in a highly systemic and extremely authoritarian way (think totalitarian
government or a fat police instead of a morality police) then I would expect it
to work. But this raises the question of
whether the ends justify the means. The
purpose of implementing public health strategies is to ultimately improve
quality of life in society, and this can be achieved by improving health and by
using money that is no longer needed by the public health system towards other
projects that benefit people. With this in
mind, it’s worth asking whether fat shaming to any degree will improve society
overall or have the opposite effect
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