Privilege, Stigma, and Better Obesity Care

Typically, Ruth Marcus writes about justice for the Washington Post. But this week, she posted a very personal essay – “the most personal piece I have ever written” – about her experience with taking Ozempic. More than just a testimonial about the life-changing effects of better obesity care, it became an exploration of the interaction between stigma, privilege, and health equity. It brought her some misgivings:

“In a just society, with a rational allocation of resources, I would not be anywhere near the front of the line to obtain a medication that is prohibitively expensive and, at least until recently, in short supply.

“If you can’t be too rich or too thin, it turns out, you might have to be rich to be thin. The racial disparities – in obesity and access – make matters even worse.

“We need to embark on a serious conversation – not about what these medications mean for celebrities on Instagram – but what their arrival signifies for the rest of us, struggling and imperfect.”

Glaring Disparities

We are grateful for the advances that better medicines are bringing to obesity care. But we hear from others who wonder, is this making disparities in health and healthcare even worse?

It’s a fair question. Even though it is also hard to imagine how much worse disparities could get. Right now, Black babies and mothers are more likely to die than White mothers and their children. The risk of death is three times higher for Black mothers. Black kids have more asthma, face more issues with mental health, and have less access to good care. The effects of these disparities and others accumulate over a lifetime and pass through to the next generation. Disparities in obesity are part of a much bigger picture of systematic discrimination in healthcare.

So does better obesity care make the disparities worse? Or does it magnify their visibility?

Adding a Layer of Bias and Stigma

Despite all of her privilege, the stigma Marcus felt because of her weight was apparent. She still remembers a tenth-grade boyfriend who replied to a question about her weight, “everyone knows you could stand to lose a few pounds.” She says she remembers a lifetime of such dings to her sense of self-worth.

People receive stigmatizing treatment from mothers, fathers, spouses, and romantic partners with disturbing frequency. Samantha Lawrence and colleagues recently documented this as a problem around the world. Bias and stigma pervades healthcare and adds further to the disparities.

Serious Work Ahead

Clearly, the interaction of privilege, stigma, and obesity care is not good for population health. Disparities in access to pricey new obesity medicines make this plain to see. Of course it’s not surprising, given the stark inequities that are pervasive in healthcare. The outstanding question is how hard are we willing to work for systems with more equity.

Click here for for the full essay by Marcus and here for her discussion about all of this with Susan Yanovsky at NIH. For further perspective on disparities in obesity care, click here.

Hopi Indian, photograph by Dorothea Lange / WikiArt

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June 8, 2023