(1)
I want to make a distinction within the field of public health: public health and the health of the public.
Traditional public health is concerned with infectious and communicable diseases. In the United States, this started with the Marine Hospital Service (later The United States Public Health Service, under the HHS), which served to fund medical care for navy sailors being ill returning from abroad. So that they don't spread foreign infectious disease in the US. The next step was the expansion of the organization into the 20th century with formalizing immigration and interstate quarantine standards. And continuing through the 20th century, the USPHS focused on communicable diseases domestically, starting with venereal diseases.
Similarly, the World Health Organization was founded as a global public health agency in the mid-1900s to address the problems of tuberculosis and malaria.
This makes a lot of sense. The 18th and 19th century saw an increased understanding of pathogens as transmitting diseases (see: germ theory of disease), as well as the Industrial Revolution, which resulted in crowded cities and consequentially worse sanitation standards for many people.
On the other hand, the health of the public is a separate issue. This is probably best associated with the Food and Drug Administration (also under the HHS). "The FDA is responsible for protecting the public health" (their own website). How so? They provide regulation and recommendation of pharmaceuticals and medical devices, food and beverages, household chemicals and cosmetics, and so on. These are not standards concerned with infectious diseases.
The health of the public is rooted in personal health, what one consumes and what medical treatment one exposes oneself to. Whether it be food that can increase the risk of heart disease, a perfume containing a chemical that inhibits pituitary gland function, or a cholesterol-lowering drug with side effects that include depression and suicidal thoughts, it's under the FDA's umbrella.
However, there is a crossroads at which these two disciplines of public health meet. The health of the public becomes a public health issue when issues arise including predatory marketing practices by pharmaceutical and fast food companies, or when health insurance or public healthcare options need funded by a general constituency or when type 2 diabetes is considered a "preexisting condition."
But what if I were to say that there is no overall perceived difference at all between these two public health functions? What happens to America then?
That is exactly what has happened. And it's served to damage our relationship with health.
(2)
What is your experience for some of the following situations?
Do you choose not to sit next to a person on a bus who is actively coughing? Do you avoid a coworker who is congested and showing clear cold symptoms? Do you ask a friend who was in bed with the flu over the weekend to not attend your dinner party?
Or what is your experience being the sick person in those situations?
Alternatively, what is your experience with mental and visual abnormalities? How do you talk differently to someone who you know is going to therapy for their depression and is talking about having called the suicide hotline yesterday? Do you stare when you're introduced to someone whose face is riddled with burn scars, or who was born with Myelitis and has a stub and two half-fingers in place of a fully-developed right arm? Do you ask about it, or do you talk around it? What's your preference in these situations if you are the one with mental illness or with visible abnormalities?
My impression of the general social consciousness and my life experiences have led me to believe that the answer is 'yes,' 'yes,' and 'yes.' To all of the above. Cough once in public, and you become an undesirable.
There is a health stigma in the United States.
(3)
Where did this health stigma come from? I think there are innumerable examples of this showing up in Western culture throughout the years, so I'll stick with two straightforward instances.
The New Testament of the Bible. It's easy to point to the verbiage used when Jesus performed his miracles curing the sick and see where modern issues may arise.
> "He [Jesus] said to the paralytic, 'Courage, child, your sins are forgiven." (Matthew 9:2).
> " 'Why does your teacher [Jesus] eat with tax collectors and sinners?' He heard this and said, 'Those who are well do not need a physician, but the sick do.' " (Matthew 9:11-12)
> "A demoniac who could not speak was brought to him, and when the demon was driven out the mute person spoke." (Matthew 9: 32-33).
> "[A leper] said, 'If you wish, you can make me clean.' Moved with pity, he [Jesus] stretched out his hand, touched him, and said to him, 'I do will it. Be made clean...Show yourself to the priest and offer your cleansing what Moses prescribed; that will be proof for them.' " (Mark 1: 40-44)
Muteness is caused by demons, paralysis by sin, and a priest is the medical authority who clears the cured leper. There is a very clear connection between physical infirmity and being cursed or being straight-up evil. This may be a ~2000-year-old text, but the cultural impact of these statements by no means quickly or, in some instances, ever, went away.
Take a step forward in time to something during our lifetimes: the Disney Renaissance, from 1989 with The Little Mermaid to 1999 with Tarzan. Although all of the films included feature this to some extent, two examples are most striking: Beauty and the Beast and The Hunchback of Notre Dame.
A classic fairy tale premise is the subversion of physical appearance with moral quality. In Snow White and Rose Red, in response to the girls' generosity for somewhere warm to stay through the winter, the otherwise-fearsome bear is revealed to be a prince who cursed by an evil dwarf. In The Frog Prince the frog, described as "wet and green and cold...horrid old Frog...wet and ugly and his eyes bulge out...cold, fat, goggle-eyed," in response to the princess being true to her promise, transforms back into a handsome prince.
And similar is the story in Beauty and the Beast, which ultimately concludes with the Beast transforming back into a prince after finding true love. "She marries the Prince, and they live happily ever after" is the story.
Of course, implicit is the part where any physical ugliness, beastliness, or deformity is a curse and that any prince's "true" form is beautiful and charming.
The Hunchback of Notre Dame takes it one step further. Hunchback Quasimodo doesn't get his transformation, so he's never even seen as an eligible suitor for Esmeralda, and instead she and Phoebus fall in love.
These are stories in which physical deformities and curse-illnesses make one intrinsically "lesser."
It's also important to note that these are all congenital, chronic, or condition-based illnesses that are being represented in the Bible and in Disney films. These aren't communicable or infectious diseases. No common cold, no malaria, no flu, no HIV/AIDS, and so on. There's no chance that Saint Peter is going to catch blindness.
We know the risks of coughing in someone's face or having unprotected sex and that those are things to avoid. We understandably are afraid of the consequences of risking exposure to infectious diseases.
However, what happens when a condition that is not infectious is treated the same way as an infectious one? And how does that even happen?
The quick answer is: visibility. You can see if someone has Down Syndrome or if they're a quadriplegic, or if someone with Tourette Syndrome exhibits physical twitches, if someone has dwarfism, or if someone has a glass eye.
Sometimes infectious disease is visible, as well. Coughing, sneezing, congestion, fever, fatigue, and so on. But not immediately and not necessarily.
You can also see if someone is fat. Obesity is treatable, though. Obesity is not permanent or entirely genetic.
And, at what point is being overweight or having a prosthetic eye a health condition? How about the ugliness of our fairy tale frog?
The visibility, the curses, the sigmas are all the same. What happens when you see someone with an "abnormality"? Especially one, physical or otherwise, that is treatable?
What happens when you conflate "public health" with the "health of the public"? And beyond.
It's the health stigma in the United States.
(3)
A quick disclaimer: not all of the following examples are concerned with health or abnormality. They are concerned with social stigma.
What has been done about health and social stigmas in the United States? A lot, really. The last decade has shown massive strides in destigmatizing some of these issues. Here's an abbreviated few-year timeline for several examples, so far as I have been able to observe it and see it recorded and reported on:
> 2012: Body positivity movement popularized on social media (anti- fat-shaming)
> 2013: Same-sex marriage federally recognized
> 2014: Destigmatization of depression, anxiety, and other mental disorders
> 2015: Destigmatization of transgenderism
But... what has happened since?
Regarding the health examples, can one so immediately reverse a culture that stigmatizes health? After generations of "just be happier" and "stop freaking out" and "what's wrong with you, needing to go to a therapist?" can we progress over the course of just a few years to understanding the nuance of mental health issues, importance of professional help, and acceptance of people despite their chemical imbalances?
Firstly, widespread destigmatization does not mean universal destigmatization. Obviously fat-shaming, homophobia, transphobia, and mental health stigmas still exist.
But what about when acceptance goes too far? What if the "slippery slope" is real?
The body positivity movement, with celebrity advocates like Tess Holiday and Amy Schumer, has transformed in part into #HealthyAtAnySize. Take a look at Tess Holiday. The majority of research in nutrition has confirmed that weight is the number one factor for heart health. Also keep in mind that heart disease is the leading cause of death in the United States. Tess Holiday is not healthy at her size. And the troops of obesity apologists on Twitter have been deluded (supplemental podcast links: 1, 2). And another side of this issue is when women like Adele and Rebel Wilson lose significant amounts of weight but are condemned for their efforts to get healthier because they're supposedly being tricked into subscribing to conventional beauty standards or are giving in to being fat-shamed.
This applies to each other movement in turn. The acceptance of formerly-taboo same-sex marriage and trangenderism has acted as a cue for fringe groups to advocate for the destigmatization and inclusion within the LGBTQ+ movement of pedophilia and zoophilia. The last several years on, and increasingly off, the internet have seen constant debate about pedophilia, from lolita hentai/artwork to the Netflix-licensed movie Cuties (succeeding films like Thirteen and Lolita) to questions about lowering the age of consent to even the questioning the moral standing for the illegality of child pornography. Zoophilia, similarly, has gained some momentum in various communities, from podcasts to internet forums. Of course, these people always existed, but the blanket acceptance and advocacy for the LGBTQ+ movement has seen attempts by individuals and communities of other taboo sexualities to co-opt this for their own platforms.
And of course, mental health. This movement has maybe seen less abusive overshot than the others but is still subject to corruption. The acceptance-turned-over-acceptance of mental disorders has led to the prominence of listing "depressed," "anxious," "bipolar," etc. as a point of pride and in one's Twitter, Instagram, dating app profile, or written fictional character. One other issue that's come up is the debate over assisted suicide and whether, with acceptance of one's depression, there should be acceptance of one's suicidal thoughts and a doctor's facilitating those thoughts into actions.
These over-adjustments to health perceptions are actively harmful. They are promoting heart disease, glorifying mental illness and suicide, and endangering children. Gender may be acceptable as a social construct, but heart disease is not.
Yes, we have made progress. Yes, it has gone too far.
What happened here? Is this just liberalism and progressivism tearing apart the fabric of our society and our traditional values?
Not really. Or, at least, that's not a good answer, I don't think.
If a fat person is treated as inherently bad, what is the proper course correction, both from within and from without? Is regularly accepting a person's excess weight issues enough? Or should we, as a culture, glorify fatness and condemn fit-ness? As reparation. As confirmation that we are progressing the right way to the right extent.
After we figured out that depression and anxiety aren't simple or well-understood issues we necessarily can't approach any future mental health condition with any skepticism. It's a knife's edge to walk, and it's sometimes the life of a person afflicted in the balance.
And what about the case when this approach comes to infectious and communicable diseases?
It has, in some cases.
Cue: Life With Herpes podcast. Much of herpes support culture has become entrenched with that single-word mission statement: acceptance. Acceptance of someone's behavior of having unprotected sex with multiple partners after testing positive with herpes.
Do you see the problem here?
(4)
Let's go back to fairy tales. What's the moral of the story here?
Culture ruined public health. As well as the health of the public.
This is the culture that spent the history of Western civilization labeling diseases and abnormalities as curses and as the consequences of sin. And then Overton's pendulum swings back to an equally-distorted extreme, and we're no better off.
So, what do we do?
Ultimately, I would suggest distinguishing between the two public health functions.
That, however, only helps with health. There's a whole basket of social stigmas here that is facing the same issues in parallel.
Broadband acceptance? "Acceptance" is a solution that ends at step one. We accept that someone is fat or depressed, and they accept themselves as not having something morally wrong with themselves. Then what? Nutrition and exercise and therapy and medication are starters. One-step thinking has clearly been part of our downfall.
Education is another start. Here's a primer on one historical example of how nutrition in America has become so horrible, here regarding the example of polyunsaturated fats and processed seed and vegetable oils. And then there's the observation of spiking obesity rates after the FDA released dietary guidelines and later, the Food Pyramid. The list goes on.
It's an ongoing cultural journey that involves learning from history.
I want to leave you all with a question to reflect on.
Next time, ask yourself this, "Is someone coughing on the train really an evil person?"