STAT News, which I quite like as a source for health journalism — other than their acceptance of funding from the pharmaceutical industry — ran a piece written by Laura Fraser.  The article covered what by now can only be understood as an extremely familiar narrative.  Namely, Ms. Fraser’s sister Jan died six months after being diagnosed with an aggressive form of endometrial cancer.  But a series of health care providers failed to diagnose accurately because they were unable to see past the patient’s fatness:

Jan might have had a better chance if her doctors had looked beyond her weight and their prejudices about fat middle-aged women; if she hadn’t been so reluctant to seek medical treatment because of the fat-shaming lectures she knew awaited her; and if she’d grown up thinking that her body was OK the way it was, and she should love it, move it, and take care of it.

This is a tragedy.  It is also all-too-common a story.  If you take the time to really listen to fat people, engage with fat activists, read blogs, zines, and narratives in the Fatosphere, stories similar to that noted by Ms. Fraser are legion.  Hence, I tweeted:

I think this is true.  Heck, I wrote a commentary on an issue of Narrative Inquiry in Bioethics that was devoted to the collection of stories like this (and others related to fat stigma).

However, I’d like to take a moment to further unpack the notion of stigma as a population health harm.  Most people, especially those connected to health care, can readily understand the idea that stigma erects barriers both to seeking treatment and to the shared decision-making that is integral to safe, effective, and humane health care.  (One of the bugaboos of the latter is known as “premature closure,” in which the provider determines, prematurely, that the patient’s problem is X and closes off further inquiry and discussion that might open up the field of potential diagnoses and interventions.  This is precisely the error that seems to so widely affect fat people seeking health care).

However, thinking about the harms of stigma solely as an impediment to health care is a big mistake, because it drastically understates the extent to which stigma harms health.

A basic point of departure for clear thinking in population health is disentangling health and health care.  Health care is a social determinant of health, but, in terms of effect size, it is a relatively minor determinant of health.  The best estimates suggest that even well-functioning health systems are not responsible for much more than 25% of a population’s health outcomes.  (Poorly-functioning systems may be responsible for less, of course).  While 25% is no small number, it pales in comparison to the effect of factors such as income, wealth, and education in driving health outcomes (see Frieden’s Health Impact Pyramid:

friendens pyramid

Therefore, I have made it a central point of my scholarship and teaching to encourage stakeholders — all of us! — to distinguish between health and health care and think carefully about what we mean when we discuss health problems and their possible interventions.  Hence the mantra of this blog: “Health is a social problem, not a technical one.”

We can draw an analogous point about stigma and health.  It is a mistake to think that the health harms of stigma are solely mediated by the extent to which stigma diminishes access to high-quality health care.  Although of course stigma DOES do this, and although of course that it does this is BAD, stigma is properly considered an independent social determinant of health.  Stigma is bad for your health in ways that have nothing to do with accessing quality health care.

Stigma is fundamentally about alienation, exclusion, and power.  Link & Phelan, two of the most influential stigma scholars in the Anglophone world, write repeatedly about what they term “stigma power.”  Because stigma is defined in terms of power structures (an in-group has to mark an out-group as deviant!), adverse social consequences always track stigma.  Stigma is corrosive.  Even when we control for every conceivable confounder, members of social groups subjected to persistent stigma and discrimination get sicker and die quicker.

Thus, even if all members of a population were fortunate enough to have excellent access to high-quality medical care, being forced to endure crushing stigma would be virtually certain to have a negative impact on their health outcomes.  This is why racial inequalities in health persist even when we control for inequalities in education or SES (“socioeconomic status”):

SES race health

(The table shows how racial health inequalities narrow but persist even as educational attainment increases).

Hence the expression: ‘Racism is bad for your health.’

So is fat stigma.

Even if fat people as a class did not have their access to quality health care severely impeded by weight stigma, the experience of that stigma is virtually guaranteed to have deleterious health impact for those people.

Stigma is corrosive.  It is bad for you.  It is bad in many ways.  Its badness includes but goes far beyond limits on access to health care.  It is a true population health harm.  We should address it as such.