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Healthcare Providers Get Our Marching Orders for the War on Fat People

by Deb Burgard, PhD

My brilliant friend Jessica Wilson has taught me so much. She is fond of asking, “What is the problem we are trying to solve?”

The question is burning in my mind after reading a recently released Washington DC think tank publication called “Provider Competencies for the Prevention and Management of Obesity”

Go take a look at this 8-page document that attempts to dictate how healthcare providers should carry out its vision, complete with a whopping 8 citations.

Back? Perhaps you noticed the 27 organizations on p.2, including the Academy for Eating Disorders, the Academy for Nutrition and Dietetics, the American Psychological Association, the American Academy of Pediatrics – organizations that many of us ASDAH members also belong to. Perhaps you noticed the utter lack of any organizations or groups from the fat community. Perhaps you noticed the instructions to have a more polite conversation (competency #6) with higher weight patients as you designate their bodies as diseased (competency #1). Or the definition of being a competent provider that hinges on prescribing weight loss (competency #5 – even as competency #9 piously advocates the use of evidence-based care.

So can we take a moment and ask:

  1. What is the problem we are trying to solve?

Are we trying to police the bodies of a diverse population with an aim to make everyone the same size?  Or are we trying to support the health of a diverse population who face many barriers to competent and complete health care, only one of which is weight stigma?

Are we trying to fight a war with fat cells or are we trying to impact a health disparity?  Are we fighting for weight normativity, or weight inclusivity?

  1. Who has input into defining and then solving the problem?

At this point it appears to be a wide variety of entities with a financial interest in policing body weight, but notably, not a single grass-roots organization representing fat people, the purported population that will be most affected by these guidelines.

It is infuriating that people who call themselves obesity experts are claiming the authority to act upon our lives and bodies when their source of information about our lives is research that is methodologically among the worst in our history. Obesity Experts are experts on a failed model of how to view and treat a problem that they have created out of the weight stigma we are all raised with. We should be humble about the vast amounts we do not know – not just in general from medical training that is steeped in weight bias, but also from medical research that rarely elucidates how to care for the actual medical issues of people who are stigmatized and face oppression.  What we do know is that the most consequential factors in health by far –  the social determinants of health – are almost never the target of intervention.  And the sources of the information, communities of actual fat people, are almost never partners in research and as far as I know, have never directed the agenda.

This has to stop.  

While you do not have to have the lived experience yourself to be knowledgeable, you do have to learn from the people who are living it, rather than the people who are stereotyping and oppressing them.  US history is littered with examples: kidnapping indigenous children to “civilize them,” white psychologists claiming blacks have “inferior IQ,” men claiming expertise about “female hysteria,” straight people claiming expertise in “the homosexual personality,” cis people deciding whether transgender people are “real,” nondisabled people designing ramps that are only reachable by a set of stairs, etc., etc.

It is almost always the actions of the targeted people who make change for the better, and now that people with non-conforming weights are more than 2/3 of the population (thank you for gerrymandering that district in our favor, thin people!) and supposedly GROWING with every breathless press release, the time is now to center the expertise of people who can teach us about the oppressions in their lives, the role we healthcare providers are playing, their resilience and skills and solutions, and how to support their well-being at every stage of change.

  1. What is the motivation for the Stakeholders?

The entities at the table producing these guidelines are indeed experts in how to make money by pathologizing a body size.  We don’t need more people to be trained to be this kind of “expert.” They call themselves “stakeholders.” They have a stake in keeping the money coming. They keep the money coming by setting up part of human diversity as a target for elimination.  Ironically, the failure to eliminate diversity is the engine driving the money – if you actually eliminate diversity, the money goes away.  So you have to keep the hate, and keep attacking the bodies that don’t conform, and keep coming up with the next big intervention that will quietly fail to make the bodies conform, after making millions.  And of course, meanwhile, the people whose bodies you are targeting are paying the price.

Monetizing the bodies of marginalized people as pathological is the blueprint.  This is how cash-strapped police departments make money with racially-biased traffic stops. How the prison-industrial system makes money by selectively enforcing a “war on crime” and a “war on drugs” by incarcerating poor, black, and brown people. How the insurance industry makes money by creating justifications for not covering sick people. How the drug industry changes cutoffs for defining disease so that they can expand their markets by labeling people sick or “at risk of being sick.”  How the data industry is building seemingly innocuous monitors to capture and sell your personal trail of identifying information to those very industries so they can add your body to the algorithm unless you have so much discretionary income that you can pay them not to.

For organizations claiming to exist for health and well-being to participate in this is despicable.  

This week we are facing the possible demise of the Affordable Care Act. Republicans are attempting to monetize the bodies of Medicaid beneficiaries on behalf of wealthy taxpayers. I am feeling the contradiction of trying to condemn a toxic aspect of the healthcare system while I am also desperately hoping we can defend it. A bit like the joke in the movie Annie Hall where one woman is complaining about the food and her friend says, “Yes, and such small portions!”  But the deeper problem is really the same, which is the corporate DNA that is amoral, which out of convenience preys upon the least powerful.  It comes back to money.  There are just some enterprises where our values must trump the imperative to make money. The imperative to grow the money is something that will always threaten every fence we build around what we value. And when we are taught, by ignorance or cunning, that some bodies have less value, we fail to protect.

Here are some skills I have learned from the labor of oppressed people:  Question every idea that assigns greater or lesser worth to certain human bodies. Question every process that claims expertise that fails to center the voices of the people living those lives. Question the motives of people – mindlessly or deliberately – carrying out the imperatives of the corporate DNA to monetize bodies. 

And for those of us facing these forces, in whatever way we do, we are the resistance. We are standing on the shoulders of our mostly anonymous ancestors in an ancient tradition that has brought us to this moment. At times it feels like we are engaged in a hopeless attempt to show up through the fog of the stereotypes and the engine of the machine, to let our lights shine and beckon our fellow humans to come back to their values. I know that they are not the problem – the problem is the problem.  The problem is the problem and the problem can be solved.

Deb Burgard, PhD, FAED, is a psychologist and activist, and one of the founders of the HAES model. She has been working on expanding the livable space for people in all kinds of bodies for the past 35 years.

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