by Fall Ferguson, JD, MA
“Nowadays people know the price of everything and the value of nothing.”
~ Oscar Wilde
I planned this blog post as a follow-up to a piece that I wrote about a year ago suggesting possible actions that the HAES community might want to consider taking with regard to workplace wellness in light of a meta-study that came out this summer looking at program effectiveness. But as I read and contemplated the current state of workplace wellness, I became increasingly uncomfortable with the discourse itself. I found myself questioning what we really mean when we talk about health and wellness in the workplace context. I find myself revisiting and questioning the pragmatic point of view I espoused a year ago, that in order to persuade employers to move away from healthist and weight-based wellness programs, we have to engage in their discourse on effectiveness.
Should we promote the replacement of traditional wellness programs with HAES-oriented wellness programs, and encourage research showing the value of such replacement programs? A year ago, this was a “no-brainer” for me. Now I find myself contemplating a more radical stance: is it possible that the entire framework of “workplace wellness” is incompatible with a multi-dimensional, non-judgmental, and socially just definition of health as contemplated by the HAES principles?
Please don’t misunderstand – I am grateful that there are HAES advocates who provide workplace wellness programs that do not use weight to define health. As long as there are workplace wellness systems, it seems important to support non-weight-focused programming. Rather, I am looking at this issue from a systems lens: I fear that the overall system of workplace wellness in its current form may be intractably healthist, racist, classist, and sizeist, and may thus harm our collective well-being far more than it helps.
ROI and Wellness Programs
Much has been made of a recently published meta-study in the American Journal of Health Promotion based on studies from 9 different countries that tends to show, among other things, that the more rigorous the methodology of a study, the less likely it is to show that a given worksite health program is effective in terms of “return on investment” or “ROI.” The highest quality studies actually yield a negative ROI. This suggests that employers may be spending more on workplace wellness programs than they “save” on costs such as health care expenditures, absenteeism, presenteeism, etc.
The importance of this study depends, of course, on who is talking. Not surprisingly, workplace wellness vendor Staywell Health Management asserted its disagreement with “those who dismiss all positive ROI findings based on the shortcomings of lower quality, less rigorous studies.” In contrast, wellness expert and HAES advocate Jon Robison asserts that the study “settles the matter once and for all”: traditional wellness programs are not cost-effective. Workplace wellness author Al Lewis is quoted by Jon Robison to the effect that the key finding of the study is, “valid studies show traditional workplace wellness is a loser.”
Editor-in-chief of the American Journal of Health Promotion Michael O’Donnell may provide the most useful way of understanding the study. While he calls it “the most extensive and well-conceived review conducted to date” he notes significant areas that are still not being addressed by researchers. Most of these deficits relate to the finer points of research methodology, but he also makes the very interesting observation that the research studies to date have not addressed the quality of the wellness programs being studied. Researchers are not looking into whether the programs address actual health needs of the people participating in them.
Is Health a Matter of Economics?
When it comes to decisions about who gets what health care services or decisions about public spending on health promotion programs, then I would answer this question in the affirmative: of course, an economic analysis must be part of the conversation. In every society in the world, resources are limited to some degree or another. It’s important for us to have intentional, collective discussions about how those resources should be allocated. For example, the Coalition for Health Funding is a U.S. non-profit dedicated to marshalling the evidence for increasing public health spending to save money on health care spending. I am all for having conversations about the best way to allocate our public spending on health in order to save lives and improve our collective well-being.
Many employers are currently obsessed with the ROI of employee health programs. This discourse has a very different quality than debates over allocating public health spending. The workplace wellness discourse focuses on whether employers can justify spending money to promote employee well-being based on their bottom line. At some point in the process, an employee’s well-being is reduced to a commodity that can be valued in dollars and cents. And all too often, that commodity is measured by BMI or waist circumference.
I used to think that the “solution” was to build better (HAES-oriented) programs and then watch as the ROI went up. My fantasy was that HAES-oriented programs would be proven so effective by the research that employers would clamor to hire HAES advocates to design their programs for them.
If Health Is a Human Right, Then We Have to Stop Treating It Like a Commodity
Now, I grow increasingly uncomfortable with conversations about “return on investment” in the context of health. In most countries, health is regarded as a human right, though not in the U.S. The World Health Organization (WHO) offers us a way to understand what we mean by health as a human right:
“The right to health means that governments must generate conditions in which everyone can be as healthy as possible. Such conditions range from ensuring availability of health services, healthy and safe working conditions, adequate housing and nutritious food. The right to health does not mean the right to be healthy.”
Contrast the WHO’s broad statement about our collective responsibility for generating health-promoting conditions with the idea that U.S. law is currently financially incenting employers to provide health promotion programs that have no known relation to the health needs of the employees but instead are evaluated in terms of ROI, i.e., the company’s bottom line. These ideas seem incompatible to me.
Healthism of Workplace Wellness Leads to Racism, Classism, and Sizeism
There is also something inherently healthist about most employer programs. While it’s possible to have a wellness program at work that doesn’t fall into this category, most employer programs create hierarchies in which employees seen as healthy and compliant are rewarded and employees seen as unhealthy and noncompliant are punished. (See this post and this post for more on this phenomenon in the U.S.) In this context, employers have the power and thus get to define what “healthy” is.
The essence of healthism is the belief that individuals are responsible for their own health outcomes; we all just need to pull our personal wellness up by the bootstraps. This illusion of control is peculiarly Western in its nature, and especially evocative of American rugged individualism. For some (for example rich, white people in the aggregate), the bootstraps approach to health may prove more accurate. For those who are poor and/or who identify with stigmatized groups within our society, social determinants of health are likely to outweigh the impact of individual behaviors.
There is good reason to fear that the implicit hierarchy embedded within employee health will disproportionately affect those with the fewest resources. Prevention Institute author Carla Saporta notes that the punitive measures built into the emerging workplace wellness system affect people of color and low income workers especially: “These workers are most likely to suffer from chronic conditions and to lack resources to improve their health, virtually guaranteeing that they will be disproportionately penalized.”
So, maybe the problem isn’t that we are talking about health and economics in the same breath. Maybe the problem is that we are having the wrong conversations about health and economics. Discourses about employers’ ROIs on workplace wellness distract us from the implicitly unfair nature of our health systems. And I fear that until we recognize health as a fundamental right, and align our social systems with that recognition, we will continue having the wrong conversations.
I leave you with questions for further consideration: As HAES advocates, do we seek to influence workplace wellness toward more humane and health-positive approaches, or do we seek to disband systems in which private employers set the terms for access to health care and health promotion, resulting in deepening health inequities? I suspect the answer may be “both/and,” but what do these solutions look like? How do we get there?