Are current discourses within the public health fields that emphasize place and geography as key components to identifying and addressing health inequities actually preventing us from seeing the existence of inequities that are not as rooted in place? I believe they are.
In October, I wrote about the need to expand the concept of health inequities to include more categories and identities that give rise to health disparities. Specifically, I noted that LGBTQ, disability, and size/weight status tend to be ignored by current public health and health policy discourses on health inequities. I argued that expanding these discourses is imperative to understanding the complexity of health outcomes among these groups. I also pointed out that this expansion is an essential step in the process of operationalizing an intersectional lens for understanding stigma and oppression in epidemiological research, our health care system, and health policy-making.
It’s important to acknowledge two relatively “obvious” barriers to the changes I am calling for here, at least with respect to size and weight. Those barriers are: (1) bias in the health professions and among policy makers, and (2) the significant and entrenched financial interests that benefit from treating “obesity” as a disease. This includes bariatric surgeons, the pharmaceutical and weight cycling industries, and even researchers and policy makers whose jobs are bought and paid for by “obesity prevention” funding.
These barriers are ever present, but it’s important to identify additional conceptual barriers that contribute to why health disparities associated with size/weight, LGBTQ, and disability are consistently overlooked. One of those barriers is the single-minded emphasis on local community, which I suspect obscures harm done by stigma that arises from identities and intersectional experiences of oppression that transcend place or geography. We need a both/and approach that allows us to acknowledge sources of stigma and health disparities that cannot be addressed by local community efforts alone.
The Settings Approach
There is a general and prevailing emphasis within the field of health promotion to focus on “settings” as a key organizing principle for public health action. There are good reasons for this. The concept originated as a way of reframing health promotion from a focus on the individual to a focus on communities and the role of social and physical environments in health. The field of health promotion routinely emphasizes local community as the appropriate locus of decision-making and action; this is often referred to as the “Healthy Settings” approach and is reflected in the organizing documents of the field (e.g., the Ottawa and Bangkok Charters). There appears to be a general consensus about what the settings approach entails:
“as well as acting to develop personal competencies, there is a desire to act in various ways on policies, re-shape environments, build partnerships, bring about sustainable change through participation, and develop empowerment and ownership of change throughout the setting.”
At their best, settings approaches draw upon systems thinking to create an understanding of how our health is the outcome of multiple levels of influences. In the Social Ecological model, for example, all human behavior and experience is seen as taking place within an ecological context of nested systems of influence and experience. Many configurations of the model suggest at least five interpenetrating system levels (shown at right): intrapersonal, or the individual; interpersonal, or relationships and family; institutional, including the workplace and other organizations; community; and society, which is the level at which public policy is generated and carried out. The levels function independently but also mutually influence each other. The model suggests that in order to be effective, health initiatives and interventions should take place at multiple levels.
Current Emphasis on “Place” Obscures Role of Non-Geographic Identities
Many current formulations of the settings approach focus exclusively on the concept of “setting” as geography, to the exclusion of other systems. There is no question that geography plays a role in health, and can be a source of health disparities in and of itself (see, for example, the County Health Rankings & Roadmaps project). Poverty and race are often linked to geography in a form of de facto segregation that has profound ripple effects on community health. Both rural and urban locales can disadvantage their residents. Access to good quality, affordable health care or fresh foods may be limited by geography. Some locations may be more exposed than others to agricultural or industrial pollutants. Awareness of the importance of local community as the appropriate locus for identifying, describing, and addressing health disparities has been driving public health efforts worldwide for a generation.
The American Public Health Association held its annual conference last month (November 2014). This year’s conference theme epitomized the contemporary manifestation of the settings concept in its theme: “Healthography.”
In a world of limited public health resources, I see most of the dollars going either to “obesity” initiatives that focus on individual blame and shame or to public health initiatives that focus on helping and empowering local communities defined by geography. This is only reinforced by the fact that public funding is often allocated by geography (e.g., in the U.S., public health dollars are usually allocated either to states, counties, or municipalities).
Unfortunately, the current focus on geography renders stigmatized identities that are not as geography-bound even more invisible. Here are my questions for the HAES® community:
- Do you agree that we need to expand our discourse of health inequities – not to leave geography behind but to include more nuanced conceptualizations of how/where stigma happens?
- How can we describe and document the non-place-bound nature of weight stigma?
- How can we advocate for programs that address weight stigma without competing for public health dollars with important locally oriented programs?
- What strategies will help us take these ideas out into the broader public health community?