Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health

Stigma is all around us – messages communicated about how you don’t fit, don’t belong, or have no value. Mostly though, unless you happen to be the one being stigmatized, it’s pretty much invisible. Think of the discomfort of flying. As a New Zealander who lives in the US, and an American married to a Paraguayan who do research together in many other countries, we are all too familiar with the experience of the 16.6-18 inch economy seat for many hours at a time.

Six years ago, our team at Arizona State University began a project tracking the experiences of patients undergoing weight loss surgery at a large nearby hospital. It changed the way we see physical spaces around us, including that narrow airline seat. Our participants began their treatment with high body masses. They detailed the many ways that the world around them constantly reminded them that they literally didn’t fit. Like the effort to exit parked cars in tight spaces and the lack of chairs that could hold them in public buildings. Some planned their entire day around navigating between spaces that could accommodate them. Of all the places they went, many told us that planes were the absolute worst; getting in and out of tiny seats, using the tiny bathroom, and the humiliation of having to request a seat belt extender at take-off.

So many explained to us that the worst thing about flying wasn’t these chronic physical reminders that you “just don’t fit.” It’s how others – complete strangers – treat you while you are struggling to fit. The exasperated looks, the sneers, and the giggles suggest somehow that you deserve what you are getting, you are wrecking things for others simply by showing up. As one participant said after losing a lot of weight: You know, [strangers] treat me differently [now] in that they don’t react to me. To them, this was a great thing. And this is how living with stigma really hurts; it’s the lack of empathy others extend you more than anything – the social death.

There’s a widespread public idea that it's somehow ok to be disgusted by obesity, to blame and shame those who are viewed as “fat”. This legitimizes those rude stares, but also allows differential (worse) treatment as discrimination. Yes, weight discrimination remains legal in the US, even as most other forms of discrimination are not. Airlines themselves legally discriminate in their failure to provide seats that adequately fit the normal range of human bodies at a regular price; most have policies requiring larger passengers to buy a second or business class seat – basically, pay a “fat tax”.

Within medicine too, there’s coolness toward larger patients, often viewed as lazy and non-compliant. Large patients say when they meet with doctors about any type of complaint, it readily gets turned back on them as only being about their weight. They can’t be related to as a person in any dimension except this one. Doctors who work primarily with the largest patients, and who are some of the kindest most empathetic people I have ever met, say even they feel stigmatized by being in the specialization.

As anthropologists, we are interested in all these types of anti-fat views as a cultural phenomenon. After all, in many societies large bodies have been considered powerful or beautiful. But we also have come to understand, through an array of our research over many years and in many countries, that weight stigma is not just a personal problem because it’s emotionally devastating. It’s an institutional problem because that medicine and public health efforts to deal with the “obesity epidemic” are probably driving the legitimacy of many of this thinking that brands the large-bodied as the cause of the problem.

It’s here that our book actually begins, looking at the implications of how powerful stigmas intersect in complicated ways with global health efforts. It’s about what happens when health professionals mistake cultural facts for scientific ones, and when blaming and shaming becomes part of the toolkit for “fixing” people.  And our book builds off the stunning revelation from the work our team – among others – that experiencing weight stigma actually makes it harder to lose weight.  That is, the very approach embraced by health professionals is probably utterly undoing their own profession’s goals. Weight is a clear example, but we have found the same type of complex counter-productive practices around stigma in many other domains too, from smoking to mental health, and in sanitation and hygiene efforts.  Stigma is all around us, constantly unraveling our collective health, and – because it is mostly invisible – it’s made worse by our best efforts to heal.

Order Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health – published on November 19, 2019 – at this link: https://jhupbooks.press.jhu.edu/title/lazy-crazy-and-disgusting

Alexandra Brewis and Amber Wutich are both President's Professors in the School of Human Evolution and Social Change at Arizona State University, where Brewis founded and Wutich now directs the Center for Global Health. Brewis is the author of Obesity: Cultural and Biocultural Perspectives. Wutich is a coauthor of Analyzing Qualitative Data: Systematic Approaches. Together, they are the authors of Lazy, Crazy, and Disgusting: Stigma and the Undoing of Global Health.