Punishing the overweight into slimness

A recent article I read about opposition to healthcare reform from the “fat pride” movement proved to be a learning moment. And it wasn’t from the story, but my reaction to it. Plus-size advocacy groups, such as the National Association to Advance Fat Acceptance, and the Council on Size and Weight Discrimination oppose proposed provisions that would penalize them for their increased health risks. Responding in part to a societal tendency to view the overweight and obese as being lazy and glutinous, these advocacy groups push the argument that you can be healthy at any size.

To a certain degree the health literature supports this idea: You can be heavier for your height than an ideal body-mass scale would suggest is healthy, but have no increased risk for disease. And there are lots of slender folks with high blood pressure, clogged arteries, and cancers. Smoking, perhaps the single riskiest health behavior, kills the skinny with as much fervor as the large. Beyond a certain size, however, evidence is indisputable: Excess weight increases the risk for conditions varying from arthritis to heart disease, diabetes to cancer.

Initially I responded with scorn: It was the “its all about me” attitude of fringe advocacy groups. I mean, “weight diversity”? “Fat pride”? Give me a break. Then it dawned on me: One of the key proposals of current health reform is the abolishment of pre-existing condition exemptions. Those exemptions currently allow insurers to refuse coverage to people who need it most: These who already have chronic, difficult to manage health conditions. There is relatively little opposition to the abolishment of pre-existing clauses as they apply to bio-medically defined diseases such as cancer or Parkinson’s. So why is being overweight any different? If we agree that it increases disease risk, how is being overweight different from cancer? Even if you argue that the causes of obesity are behavioral rather than genetic, it still pre-disposes you to increased disease risk, plain and simple. And risk factors for many conditions such as cancer and heart disease, which most people are comfortable giving pre-existing condition status, are heavily influenced by behavior.

Perhaps most importantly, lifestyle causes for obesity are socially constructed: Economic incentives to over-produce fattening high fructose corn syrup; mass advertising of nutritionally poor, high calorie fast foods; housing, transportation and workplace trends that discourage exercise; all of these are designed to make us fat. People don’t arrive at fatness by choice, they are led there by following social signs and trends. Finally, punishing people for unhealthy behaviors that are socially promoted may not be the best way to induce healthier choices. It’d be more acceptable to do this with overweight folks than those with cancer, but no less unjust, and no more effective. How does making it more difficult to get healthcare help people improve their health? Would you argue that obesity is a lifestyle choice that warrants punishment? Do you suppose that approach would slim down our epidemic of fatness?

Homosexuality, hate crimes and health

President Obama recently signed a law extending federal hate crimes protections to gays and lesbians. Its about time. Human and civil rights and safety from persecution and violence are fundamental cornerstones of public health. The FBI reports that of the 7,624 hate crime incidents in 2007, 17 percent were based on sexual orientation. This most certainly represents an undercount, since not all such crimes are reported, and until now they did not have the official designation of hate crime.

Thankfully, hate crimes are rare events. But this new law has other potential health benefits that are far more profound. Acknowledging that abuse is unjust or criminal helps to acknowledge that as a society we recognize the essential humanity and value of the individual or group suffering the abuse. Providing not only protection of law, but also recognition that a social group is valued and worth protecting helps to increase their level of social support and social integration, while decreasing their sense of isolation and the need to constantly be vigilant against attack. The public health literature is rich with evidence linking higher levels of social support, social integration and trust with better health, and higher levels of isolation with poorer health.

Marriage has also been linked to better health and longer life, and the growing movement worldwide to grant marriage rights to same sex couples continues this social evolution towards not only a more dynamic and just society, but also a healthier one.

Discrimination against homosexuality has long been justified by health bigotry and pseudo science, invoked both through intentional malice or old fashioned ignorance. On the health side, discussions of gay or lesbian health are frequently dominated by concerns about AIDS/HIV and risky sexual behavior, even though these populations obviously face many other health challenges as well.

And many people have attempted to leverage science to support the “its not natural” argument about same-sex couples. In truth science proves that the rigid construct of what constitutes male, female, and the respective roles of each is purely a human creation. Take earth worms. Every worm is equipped with male and female reproductive organs, and they choose which gender to assume at each mating. In some cases they lose their male genitalia, and continue life as permanent females. A small tropical fish called the wrasse is capable of a similar gender-morph: A single male lives with a harem of females, but when he dies, the dominant female becomes a male, and assumes his duties. From the warm blooded mammalian world, up to 18% of rams attempt to mate exclusively with other males, even when females are available. Not that those examples are necessary for us to simply do the right thing: There’s nothing “natural” about democracy, money, hospitals, mass transit, or vacations in the South of France, but who has a problem with them?