Sunday, October 23, 2016

Public Health Strategies Part 1: Blaming and Shaming

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