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Obesity, Health Advocacy and the Imaginary Geographies of Illness

Scott Stoneman, McMaster University

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When the world was a simpler place, the rich were fat, the poor were thin, and right-thinking people worried about how to feed the hungry. Now, in much of the world, the rich are thin, the poor are fat, and right-thinking people are worrying about obesity.
- Anon. The Economist (US). (Dec 13, 2003).

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[2] The most common way to begin a commentary on the obesity epidemic is to rehearse a series of statistics that are meant to support the idea that obesity rates have become a “crisis by any standard” (Pomeranz 186). Then, typically, experts will list the chronic health problems associated with obesity as a means of reinforcing the semiotic applicability of the word “epidemic” to the ostensibly normative issue of there being too much weight on people’s bones. Rather than performing these by now familiar rhetorical moves, my point of departure will be to recognize that although the material basis of obesity panic is the social reality represented by the gradual bloating of these numbers, the obesity epidemic is more aptly to be understood as a particularly speculative and instrumentalist “epidemic of signification,” to use a term from Paula Treichler’s study of AIDS and the intersection of science and morality (1). Indeed, at no point in human history has the collective weight of a population possessed the gravity or borne the intensity of political consideration that it does in our time. At a time in which the global flow of populations and the accelerated global movement of capital destabilizes appeals to the familiar paternalism of the nation-state, fatness and the symbolic weight of an increasingly fat body politic feeds a renewed state concern with social reproduction and public concern over the unsustainability of contemporary life under our increasingly banal conditions of crisis.

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[3] In September of 2007 University of Washington researchers headed by director of obesity research Adam Drewnowski found that the most reliable way of predicting whether a particular population had lifestyles that made them vulnerable to obesity was to look at U.S. property values by zip code (Drewnowski, Rehm and Solet). A household’s wealth, the cost of people’s homes, more than any other factor, signaled the susceptibility of bodies to the network of habits and patterns assumed to be constitutive of this endemically urban, 21st-century epidemic. Perhaps the most persistent unsolved mystery of the so-called “obesity epidemic” is how the economic constraints which govern the way space is structured and used compel “obesogenic” or fattening patterns of everyday physical activity and eating. Increasingly, a combination of social and physical planning and an overarching logic of growth render certain neighborhoods inexplicably unhealthy to live in.

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[4] In the words of noted U.S. obesity researcher Kelly Brownell, “when one looks to population increases in obesity, we ask, for example, why Japan has more obesity this year than last, why some nations are heavier than others, why an entire population is vulnerable to changing diets, and what might be done to reduce the problem.” Brownell writes that looking at the issue of weight biopoliticallyi means there can only be one explanation for “rampant obesity”: “the environment has become fattening or ’obesigenic’ [emphasis added]” (Brownell 164-165). It is telling, though, that scholars and The Economist’s other “right-thinking people” are not entirely sure how or why, in areas of deepening poverty, people are compelled to adopt lifestyles that make their BMI an apparent blight on the state. The debate in obesity science over the built environment is still highly speculative, with many of the increasing number of studies which compile data on the way spatial and environmental factors influence eating and exercise reporting the inconsistency of measurement criteria (Booth, Pinkston and Poston 2005; Papas, Alberg and Ewing et al. 2007). At issue in this case is the manner in which the relationship between obese bodies and the built environment gets imagined in work which advocates for the increased regulation of the ordinary: food and movement. As one article in the Journal of the American Dietetic Association put it, “The primary question facing researchers investigating the built environment and obesity is whether community design factors might prevent individuals from engaging in physical activity while encouraging them to select and eat more energy-dense and low-nutrient-value foods, thus contributing to the obesity epidemic” (S111). That the modus operandi for developing knowledge about the causes, consequences and, in a sense, the ontology of this chronic health condition is presumed to be restricted to coordinating a multi-nodal campaign to triangulate and erase obese bodies, and eliminate the structural forces which create them, is not surprising given the prevailing rhetoric of the “obesity epidemic.” Whether design de facto determines activity or encourages particular eating practices, or whether a systematic plan to reduce rates of obesity could exist given its targets are “random events and systems virtually impossible to predict or control” (Gard and Wright 6), medical deduction and the assumption that poor populations are desperately and self-destructively overweight determine that, discursively, design does and a plan must.

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[5] The built environment comprises, to put it simply and objectively, the whole of one’s man-made surroundings. Linking nation and neighborhood, it is also a question of property rights and the construction of “geographical networks and systems of exchange for money and all commodities, including labour power itself” (Harvey 108). But in the context of public health fears over the sudden statistical prevalence of obesity, the built environment as an objective of research and reform is not strictly economic, insofar as it summons existent fears that consumer culture and contemporary urban and city life are, in some sense, predatory on a population-wide scale. Thus, the question of the built environment has taken on the significance it has in obesity science and its satellite discourses because, in providing an expedient etiology for the obesity epidemic, it names the degree to which the accelerating privatization and commercialization of everyday life leaves citizens helpless and subjects heteronomous as social agents. As a conceptual framework, the built environment is taken up to explain the incidence of “endemics.” Summarizing Michel Foucault’s lectures on the subject, Rabinow and Rose define endemics as “illnesses that are routinely prevalent in a particular population and sap its strength[,] requiring interventions in the name of public hygiene and new measures to co-ordinate medical care” in the interest of managing the impact on bodies of “geographic, climatic and environmental conditions” (“Biopower Today”). The obesity issue dissolves the distinction between endemic and epidemic in large part by pathologizing the very environments in which we live.

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[6] The belief that environment has an objective and alterable role in regulating individual or collective action, and that is possible to calculate how and whether the spaces of individual and collective action produce a positive or deleterious effect on human health, has in recent times led to alarmist rhetoric concerning the need to protect the national economy and its military apparatus from the perceived drain of having too many obese citizens. An acutely symptomatic 2006 statement from Surgeon General Richard Carmona puts obesity panic in perspective; Carmona asks: “Where will our soldiers and sailors and airmen come from? Where will our policemen and firemen come from if the youngsters today are on a trajectory that says they will be obese, laden with cardiovascular disease, increased cancers and a host of other diseases when they reach adulthood?” (“Obesity Bigger Threat than Terrorism?”) The child as couch potato becomes the exemplary figure in a discursive war over the symbolic fallout of fat.

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[7] Obesity in children takes on an especially charged position politically, as the question of a childhood obesity epidemic focuses the more radical implications of this debate over the built environment. Alarm surrounding the prevalence of childhood obesity is codified through the coining of cryptic-sounding terms like “sedentary death syndrome” (Lees and Booth 447) and “nature deficit disorder” (Louv 10) which, scores of news sources daily inform us, threaten the mythic innocence of childhood experience (and the labour power children represent) with the burden of obesity. Reduced to a terms which medicalize or financialize obese bodies, the cultural codification of fat in the context of a childhood obesity epidemic suggests that the debate over the relationship between obesity and the built environment is, in fact, a debate over whether the human as species-being is facing a crisis of self-regulation or something more insidious: the evolution of environment that takes place, as Marx put it, “behind men’s backs,” a process also known as accumulation in Marxist theory (qtd. in Trotsky 86). Indeed, one of the things that is unique about the contemporary effort of medicine and the social sciences to control and reverse the spread of obesity is an active interest in what Clare Herrick calls the “diminished autonomy” of at-risk children under contemporary regimes of capital (98). The idea that children are coerced and corrupted by the organization of space finds a unique venue in obesity epidemic discourse, where the obese body is read as irrefutable evidence of the abandonment of bodies to the accumulation strategies of advanced capitalism. In this body of work, the obesity epidemic becomes, in the words of critical theorist Lauren Berlant, “a way of talking about the destruction of life, of bodies, imaginaries, and environments by and under contemporary regimes of capital” (764).

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[8] The Canadian government’s recently renewed “ParticipACTION” ad campaign makes the point that kids have got to get outside in perhaps the most lurid way imaginable. Chubby kids are seen playing bingo and driving motorized wheelchairs, discussing pacemakers, bypass surgery, heart attacks and colonoscopies. In caricaturing Canadian kids as indistinguishable from octogenarians, prematurely immobilized by age and illness, the campaign tactically adopts a pedagogy of hyperbole. The implication is that children, who queer theorist Lee Edelman argue “come to embody... the telos of the social order and come to be seen as the one for whom that order is held in perpetual trust” (11), move between conditions of confinement and addiction which forfeit their bodies to chronic health problems: the home with its virtual amusements, the school and the mall with their endless indulgences. Private comfort or uninterrupted shelter, in the case of most Western kids, excludes the out-of-doors and, the story goes, displaces play from childhood altogether, leaving us with an idle class of kids whose allergy to activity will leave them unprepared to reproduce the social.

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[9] It is important to point out, however, that even in the satirical context of the ParticipACTION ads, the child is not understood as a citizen per se, but as a “dividual,” or statistical unit, to employ a term from Gilles Deleuze (177). Perhaps most basically, the figure of the obese child in any biopolitical investigation of the problem is used to illustrate the function of what Melanie Dupuis and Julie Guthman term accumulation by engorgement: “[David] Harvey’s ‘accumulation by dispossession,’” they explain, “has its counterpart in accumulation by engorgement in the spatial fix of the body. For the body is not only a site through which capital circulates as labor power, it is also the site through which capital circulates as commodities” (Dupuis and Guthman 442). The crucial point here is that the crisis of sustainability endemic to the economic project of global neoliberalization is worked out in the body. For Guthman and Dupuis, obesity conveys to us a clear sense that under the competing forms power takes in multifarious Western social contexts under globalization, the body is nonetheless globally the object of market strategies. Thus, the body is required, under these strategies, to continue consuming far in excess of its needs.

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[10] The result, according to Megan Purcell, is a more serious threat to the child’s very political subjectivity. Purcell argues that obesity poses a potential obstacle to the child’s development of meaningful legal and political citizenship. That said, the rhetoric of radical change, and even, in Purcell’s case, of social justice and obesity, is based on the notion that we have a clear idea how to manufacture long-term weight loss in populations. We do not, in fact, know how to accomplish this. But more significantly, the fantasy that the study of everyday uses of space, the measurement of the amount and time that people walk, the nature of their desires when they eat, and of their feelings toward the public reduced to a sphere of physical exertion or energy expenditure - that these things can be adequately measured as a means of remodeling a built environment governed chiefly by opportunity and the logics of accumulation by dispossession and by engorgement, is the utopian fantasy of a group of intellectuals with no dialectical sense of the political implications of intensified intervention in everyday life. While the fantasy of increasing the public’s “demand for health” is well-meaning, it is not necessarily benign (Herrick 97). Consider Michel de Certeau’s indictment of statistical investigation: “Statistical inquiry, in breaking down these ‘efficacious meanderings’ into units that it defines itself, in reorganizing the results of its analyses according to its own codes, ‘finds’ only the homogeneous. The power of its calculations lies in it ability to divide, but it is precisely through this ana-lytic fragmentation that it loses sight of what it claims to seek and to represent” (De Certeau 69). While extant analyses of the problem link obesity and environment in a causal relationship, scholars, journalists, policy-makers and others responsible not just for meeting totalizing targets for public health, but for exploring the place and meaning of public health in our time have rarely linked evidence like the trends Drewnowski’s team uncovered to obesity’s cultural implications. What does it mean that, in the words of Michael Gard and Jan Wright, “we all find ourselves in an environment that panders to our allegedly slothful nature” (Gard and Wright 32)? And what does it mean that, today, those who call themselves “right-thinking people” are authorized to react against obesity by imagining the means of correcting the poor’s poor choices regarding the needs of the body?

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[11] To understand the peculiar event-like nature of obesity, we have to begin at the moment of the epidemic’s cultural inauguration. At the turn of the millennium, Center for Disease Control representative William Dietz unveiled a series of “infographics” (http://www.cdc.gov/obesity/data/trends.html) which he and Ali Mokdad had created as a means of demonstrating that the steady climb of obesity rates over the previous fifteen years was actually an outbreak, making it an issue of necessary governmental intervention on behalf of the health and vigour of a population increasingly infected by its environment. In the images, “hot zones” appear across a set of maps of the United States; particular areas slowly turn deeper shades of blue until, dramatically, red states appear and darken ominously. Dietz and Mokdad’s maps have since been disseminated widely, providing the foundation for subsequent efforts by health professionals to map out of the obesity issue.

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[12] Dietz’s use of this map was what Berlant calls a “redefinitional tactic, a distorting or misdirecting gesture that aspires to make an environmental phenomenon appear suddenly as an event” (760). The information he revealed was not only already available, it was widely known and acknowledged. But rather than simply reproducing the numbers, Dietz reinscribed the data in spatial terms. And it worked. J. Eric Oliver makes the case that the “visual power” of Dietz’s diagram lies in its ability to redefine obesity as a “spreading infection” (614). It is worth quoting Oliver on the issue:

Obesity, viewed by many as simply a consequence of lifestyle, was now seen as a disease transmitted across populations. Dietz... held a view that was becoming more prevalent within medicine: that obesity was strongly influenced by the environment and was a condition that people passively experienced, something that happened to them rather than simply the result of their choices (614).

One should also note the openness with which Dietz’s explanation of his map’s intended effect advocates for instrumental rationality: “After people have seen the maps, we no longer have to discuss whether a problem with obesity exists. These maps have shifted the discussion from whether a problem exists to what we should do about the epidemic” (Oliver 616). Dietz’s map recodifies and ontologizes obesity, catalyzing a transition already in progress from speculation to active intervention.

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[13] But the problem remains: how does one “cure” the unsustainability of contemporary life? What remedy is there for the built environment? Or, even more simply, how do we determine the influence of space on people’s bodies? Hayne writes that “[c]hanges to the existing built environment, even with political support, are not easy to implement and will only happen over time. Buildings, roads, and neighborhoods, once in place, cannot be easily altered. Regulation may offer guidance and alter incentives for future development, but it remains unclear which design features will prove the most successful in promoting physical activity” (399). I contend that obesity exposes the things which most mystify and trouble us about the ways that the economic and cultural complexity of space, or power, shapes bodies. Indeed, it could be argued that, in diverse professional and political registers, obesity has sparked a debate over the central problem of what Gilles Deleuze called the society of control: how is the democratic potential of people to “act back on space” (Clarke 191), or critical agency, attenuated?

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[14] In the last of his lectures, Michel Foucault unpacks the notion of “thickness” as a means of describing the collective aggregate of “a spontaneous bond between the individual and the others” (352). It is important to Foucault that while this spontaneous social bond, what we could too narrowly call cooperation, existed before and exists in excess of government (and is as such not in any way an effect of government), it nonetheless becomes the primary locus of governmental strategies through the use of statistics. In other words, the discovery of this immanent “thickness” or the indeterminacy and multiplicity of human cohabitation heralds the development of a form of “governmentality” which requires the generation of inchoate kinds of knowledge in order to manage and regulate the micro-dynamics of populations. The knowledge required is knowledge concerned with the population “as a reality that has a natural density and thickness that is different from the set of subjects who were subject to the sovereign and the intervention of police” (352). The development of capitalist markets and the emergence of “urban objects” produce a liberal configuration of the political, in which subjects are represented instead as citizens in the narrow sense of being members of a population. Preventive medicine, with its twentieth century origins in eugenics (Rose 58), is the order of the day for shaping the knowledge produced and the political injunctions prompted by the perceived vulnerability of populations to obesity. The form obesity prevention takes today is in some ways familiar from past public health campaigns (anti-smoking is a well-known and model case), but in other ways quite distinct. What Michael Gard calls the “obesity vortex” - a torrid intensification of knowledge production concerning obesity - has concatenated popular culture, medicine and public policy to create a discourse on obesity that is, in Gard’s words, “replete with untested assertions” (Gard 76). Most pressing here is the question of how the intensification of the obesity vortex marks the translation of reductionist science into “ineffective solutions, and at worst... oppressive social policies” (Gard 72).

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[15] The notion that environment determines everyday patterns of behaviour, and that those patterns should be policed by reordering the environment in the service of objective “health” has been around since at least the early 18th century. Since-we might say-the birth of biopower, bodies have been understood as the habituated aggregation of a general social “atmosphere,” or societal constraints. What is different, though, about the mode of governmentality which forms the crux of the current “war on obesity” is the extent to which, in coordinating diverse disciplines in the service of a singularly medical campaign, it camouflages its inherent classism by asserting and reasserting how difficult it is to determine, and thus to regulate, the indeterminacy of everyday life. The obesity obsession that characterizes our current global moment is intensifying despite the medical establishment’s admission that, even with the explanatory framework of obesogenic environments, it is in a state of crisis over how to measure and remodel the social’s impact on the tissue of individual bodies (Boon and Clydesdale 2005). Seeking conceptual innovation, it has begun to imagine technologies of regularization that are uniquely motivated by the sense that, as Jean Baudrillard put it, man is the “active engineer of atmosphere” (Baudrillard 316).

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[16] What has caused obesity to spark such theoretical curiosity in the sciences regarding the gaps and tensions between everyday life, space, and governmentality? In the interest of “health literacy,” why does the conceptual vocabulary applied to the effects of the obesogenic environment not provide heuristic or hermeneutic resource to the people for whom obesity is allegedly a serious health problem?

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[17] We are increasingly surrounded by the message that fat is fatal because of a latent anxiety regarding the erosion of the rational autonomy of the individual (the basis of liberal political theory’s conception of the human) under the uncontrolled social conditions produced by advanced capitalism. Yet much of the rhetoric surrounding childhood obesity invokes the tenor of a moral imperative, and thus we might take the opportunity to pose difficult questions. What kinds of utopian possibilities are necessitated by an epidemic of childhood obesity? How do we take the pitfalls of screen media preoccupation seriously? What do we mean when we identify a “nature deficit”? What form does the question of liberation take when the child is conceived of as a body victimized by what Harvey calls the “consumptuary apparatus of capitalism” (111), and paralyzed by screen culture and urbanization? An oppositional discourse on the relationship between obesity and the built environment must be imagined which links private anxieties with public concerns, obesity to a critical concern with the public good, and, more broadly, the criticism of systemic forces to the aporetic and anticapitalist challenge of liberating everyday life.

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Footnotes

  1. By biopolitical I mean statistical, but statistical in the specifically political sense of culling statistics not neutrally or objectively but according to already existent systems of value and for the purpose of monitoring the materiality, vitality and morbidity of bodies.

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Works Cited

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