The Crippling Weight of Stigma: A Closer Look at a 2012 “Anti-Obesity” Campaign
It’s a special case study in how public health authorities do harm.
In January 2012, the New York City Health Department promoted a controversial “anti-obesity” campaign that was meant to bring attention to the dangers of “super-sized” portions commonly found in fast food restaurants and convenience stores, which are described as having grown over time. One image in particular was described as especially graphic — it featured a fat Black man sitting on a stool. His right leg appeared to be amputated. Crutches leaned dramatically against the wall behind him. It was later discovered that the man’s image was pulled from a stock photo and that he was not an amputee; the advertisement agency contracted by the Health Department had performed an amputation via Photoshop. The crutches had also been added through photo editing. This campaign, as well as the reactions to and criticism around it, present an opportunity to examine the substantial overlap between fat stigma and disability stigma, how these stigmas are weaponized by health authorities, as well as how, despite performed deference towards socially-focused approaches, public health actually ascribes to a medical model in its approach and conception of fatness and disability.
Historically, disability has been understood through the medical model, which positions it as a consequence of physical deficiency in need of curing or intervention. The medical lens was largely shaped by the overwhelming influence of the biological sciences and the authority of the medical profession in the west during the late 20th century. The disabled person, who requires reasonable accommodations to participate in society at a socially-desirable level is blamed for their needs. They are culpable and their level of culpability increases in proportion to the possibility that they may have prevented their impairment. As something that must be cured, disability is also attributed a varying level of mutability within the medical model. Whether or not an impairment is actually curable doesn’t necessarily eliminate mutability from this understanding of disability; the clinical perspective asserts that disabilities are always worth curing and that there will always be a need for medical intervention. The medical model remains the popular understanding of “disability.” The campaign being referenced is derived from this model; however, its uniqueness comes from its placement of anti-fat sentiments within disability’s medical model.
Brandon and Pritchard conceptualized the idea of “being fat” through three contrasting models of disability — medical, social, and affirmation — in order to address the question of whether being fat should be regarded as a disability or impairment. Similar to disability, “being fat” is a condition that allows authorities to intervene in the lives of people beyond normative intervention approaches; is driven and structurally imposed by capitalism; is socially and economically discrediting; and contributes to a democratization of the fat body that allows for there to be collective societal panic over the current and future existence of fatness. With regards to the latter, fatness and disability have both been discussed as problems that must be solved for the betterment of wider society, rather than thought of as manifestations of human diversity. As Lucy Aphramor posited in 2009, the striking similarities between dominant agendas for “solving” disability and fatness work similarly to inscribe bodily diversity within the biomedical model, all while depriving fat and disabled individuals of their autonomy and voice. Reduced down to their bodies, individuals living along or at the overlap of these axes of oppression are rarely understood outside of the clinical “rubric.”
While medicine’s alignment with the medical model has been thoroughly noted, the field of public health often differentiates its approach from the limiting nature of medical models of health and, by extension, disability. For instance, in “Public Health 101” course materials from the Centers for Disease Control, health determinants include “social or societal characteristics” alongside “genes and biology”; similarly, socioeconomic variables such as “poverty reduction” are described as impacting health in tandem with “healthy decisions”. This phrasing is a normal feature of introductory courses in public health schools and programs. In the way public health points to social factors as contributors and facilitators of health and disease, it claims to operate in close proximity to social models. The social model of health situates health and wellness of people and communities within social contexts that are understood to promote and degrade health in different ways. The social model of disability distinguishes physical impairment from the disabling social exclusion that disabled people face, which severely impacts their quality of life. Simply put, social models of health and disability assert that conditions — sickness and disability — are imposed and shaped by society. However, as I will explain using the mentioned campaign, public health’s approach to fatness and disability contradict this invented alignment with social models.
The campaign in question, in its attempt to tackle an “[obesity epidemic] driven more by cultural and political factors than any threat increasing body weight may pose to public health”, utilizes messaging that emphasizes the culpability and mutability of fatness and disability. The images, of a fat amputated man hunched over on a stool and growing cups of soda, very clearly connect personal choice, in the form of soda drink size, to fatness and fatness to amputations. The result of these connections is the communication of a second message besides the danger of soda: fat people who eventually require amputations as a result of a preventable, or mutable, condition only have themselves to blame. Important to point out is that the diabetic amputee, according to the NYC Health Department, is not culpable due to potentially life-altering choices about factors like education, employment, or housing, even though these factors are frequently connected to health and fat people face discrimination in these domains; a diabetic amputee is culpable specifically because they lack the self-control to not consume large quantities of sugar-laden foods and beverages, but the crime only exists within the medical model of disability. This accusation is also completely divorced from the social reality that makes fatness, as mentioned, socially and economically discrediting, thereby eliminating any possible alignment with social models of health and disability.
Also worth mentioning are how the responses to this campaign further reflect the medical model’s perception of fatness and disability, as well as the far reach of these ideas. The American Beverage Association (ABA), a lobbying group membered by various soft drink producers, was featured as an open critic of the campaign in the media coverage the followed its rollout. They claimed the NYC Health Department was illustrating an “inaccurate picture” of the consequences of soda drinking. Stefan Friedman, an ABA spokesman, said the campaign was excessive and “instead of utilizing scare tactics, the beverage industry is offering real solutions like smaller portioned containers and new calorie labels.”
NYC Mayor Michael Bloomberg ardently defended the campaign. He responded to a reporter’s question regarding its graphic nature and ABA’s comments with the following: “What do you want to do? Do you want to have people lose their legs? Or do you want to show them what happens so that they won’t lose their legs? Take your poison. Which do you want?” (Lamb 2012)
Mayor Bloomberg’s response reaffirms the high levels of perceived culpability and mutability of disability in fat bodies that were first pushed forward by the Health Department through this campaign. The choice, forced by an official and agency that position disability as a terrible punishment, between being further stigmatized in a campaign or losing limbs doesn’t serve any real purpose; this false choice is just a vehicle by which to emphasize a normalized disgust toward fat disabled bodies.
Notably absent from all of the media coverage corresponding to the campaign are fat disabled activists or spokespeople from organizations that advocate for fat and/or disabled people. Rather than soliciting criticism from people with lived experiences of fatness and/or disability, the media focused on the back and forth between the ABA and city government, effectively leaving the critique of this gross campaign to corporations who prey on the same people they are supposedly defending. The complicity in upholding the medical model is not restricted to the actions of health promotion officials or institutions.
There are many who would vehemently disagree with my arguments here and state that public health’s consideration of social determinants of health in several areas outweigh its disregard for them in “anti-obesity” campaigns like this one and many others. My argument — that public health to an exclusionary and oppressive medical model of disability — would be derided as an overgeneralization. There are also many who would and have argued that the use of stigma for “good” purposes, such as preventing “obesity” and subsequent amputations, is justified. These responses are flimsy and baseless.
Stigma is a commonly studied variable in many different subfields, particularly HIV research. Public health officials and institutions understand the torrential health effects of stigma. Yet, as noted by Cat Pausé, “campaigns to combat the obesity epidemic often rely on stigmatizing images of fat people accompanied by stigmatizing text… Campaigns such as these use graphic imagery to produce fear and disgust in order to provoke behavioral change.” Similarly, discriminatory language against disabled people (‘retarded’, ‘subaverage’, ‘deficiency model’) and normalized ableism (‘failure to adapt’, ‘challenging behaviors’) are common features of public health literature, materials, and programming and disability is often discussed as a consequence for poor health behaviors and outcomes. These are norms in the public health domain.
But we know stigma is harmful and hurts people and doesn’t even positively impact behavior change in them. So what gives?
When it comes to the stigmatization of fat and disabled people, our well-researched understanding that stigma is harmful does not matter. It does not matter because we believe fat disabled people to be responsible for the state of their bodies and in charge of either fixing them themselves by making better choices or surrendering to unending intervention by medical institutions and practitioners. They must be punished, deprived of full autonomy and decency and respect, because they are culpable, and their fatness and disability are mutable if only they had more willpower. As specimens who fail to meet the criteria for human treatment, fat disabled people do not have access to full consideration within the social model that is afforded to other individuals who are seen as struggling with adverse health effects, who are seen as worthy of empathy and dignity and contextualization within an unequal, unjust society. I ask those who believe public health is a socially focused, highly ethical field, despite its treatment of fatness and disability, the following: Why is the regular dehumanization of fat disabled people not a basis for reflection on our field? Why isn’t that important enough?