Читать книгу Extreme Weight Loss - Amber Wutich - Страница 8

We started laying the groundwork for our study on bariatric patients in 2012 and began formal ethnographic research in the clinic in 2014, but we have been engaged in studying weight and weight-loss issues for much longer. In fact, our individual research trajectories are very illustrative of the major shifts that have happened around health, weight, bodies, and nutrition research in our lifetimes alone. Alex began her ethnographic fieldwork in the islands of the central Pacific thirty years ago, when anthropologists were still overwhelmingly engaged with many smaller-scale and subsistence societies that placed a high value on weighty bodies. Alex’s long-term research in Samoa, in particular, has tracked shifting preferences and beliefs, showing an accelerating seismic shift from that traditional plump ideal to a vague preference for being thinner (which made an appearance two decades ago) to today’s strongly negative ideas about fat. Sarah’s research in the United Arab Emirates among female university students in 2009–2011 revealed that young women there expressed considerable worry about weight and invested time and energy in often-draconian efforts at dieting, in stark contrast to the pro-fat attitudes that predominated in their grandparents’ youth. Similarly, Amber’s decade of work in Paraguay has uncovered profound ambivalence around changing body norms. Many urban Paraguayans reject anti-fat discrimination while also holding harsh anti-fat views, which manifest themselves socially through men’s and women’s teasing and judgment of bodies identified as fat.

In 2010, we conducted a set of standardized surveys across a range of different low- and middle-income countries in East Africa, the island Pacific, and South America. We found that consistently strong anti-fat sentiments had become normalized across all the cultures we surveyed.18 This was a shocking finding at the time because many of the cultures we studied were still thought of as fat loving. Yet people consistently identified fat as unhealthy and unwanted and categorized fat individuals as lazy, uneducated, and unmotivated.

Of course, this was not a monolithic attitude; our samples were biased toward urbanites, who were regularly exposed to transnational media messages that equate fatness with badness and public health messages that stress obesity as a risky health condition. Additionally, there were people across all settings who stated that they found large bodies (including their own) not only acceptable but even good. Existing ethnographic research in diverse cultural settings also shows that people may simultaneously hold positive and negative ideas about fatness versus obesity and may focus on the negative frameworks when asked in an official capacity to provide ideas. In other words, long-standing cultural ideas that value larger size still retain power in many settings worldwide.19

Nevertheless, those survey results showed that more people overall see fat bodies as unacceptable and bad and will say so. In the survey data, we established that no cultural context we studied—no matter how fat positive it had been historically—was immune to the anti-fat attitudes and rhetoric that gathered momentum throughout the last half of the twentieth century. Moreover, the range of socially acceptable bodies seems to be narrowing in all of these cultures. On the other hand, the strength of expressed anti-fat convictions and the effort, money, and time people are willing to expend to meet new body norms differ from place to place. The US remains one place in the world where the drive to be thin is consistent and internalized and where people with identified fat bodies struggle across many spheres of life, including the workplace, educational settings, and social and familial circles.

Despite several decades of collective work related to weight and body in places as diverse as Paraguay and Bolivia (Amber); Mexico, Samoa, South Korea, Japan, and the US Southeast (Alex); and the United Arab Emirates and the US Southwest (Sarah), we often found ourselves listening to people who did not identify as either clinically obese or socially fat. We are certainly not alone in this. In the past few years, a critical corpus of ethnographic work engaging with obesity, fatness, and body issues has developed within anthropology and sociology, exploring the various ways that people engage with globalizing messages that vilify obesity and fat in daily life. With a few exceptions, such work has not explicitly focused on people at the high end of the weight spectrum, those most pathologized by the medical world. Where this work has had such a focus, the research tends to have tiny sample sizes; self-studies (“autoethnographies”) are common. This work also tends to be oriented around fat acceptance and/or fat positivity. “Health at Every Size,” an agenda that advocates accepting all body sizes as part of a holistic view of health, is also a common framework and point of departure for this research.

Our conclusion is that outside of Fat Studies, anthropologists have not been comprehensively attending to the stories and ideas of those who most struggle to fit dominant body norms because of high body weight, especially in contexts that are highly fat stigmatizing and spurn fat acceptance ideals. For example, the bariatric participants with whom we spoke, who were very large people in a virulently anti-fat setting, were not interested in a revolution that overturns the current stigmatization of fat. Rather, they devoted their emotional efforts, time, and money to changing their physical bodies to better fit current body ideals. Most of the clinic patients we got to know articulated deeply held beliefs that being fat is unacceptable. Even patients who did question anti-fat norms and registered lower levels of fat stigma nonetheless fundamentally believed there was something wrong with their size and therefore with themselves prior to bariatric surgery.

We think another reason that anthropologists have not focused much ethnographic attention on understanding how very large Americans relate to the extreme body norms circulating in the US today is because of the difficulty of the fieldwork. The study of norms, at least as anthropologists approach it, requires that researchers talk to enough people to understand shared concerns and themes. For what we wanted to do, including thematic analysis, one or two cases was insufficient. We needed a robust sample size that was big enough to accommodate loss of participants over time while still meeting the minimum requirements for participant observation and qualitative data analysis.20 Moreover, recruitment in anthropology in complex urban settings (we based our study in a city in the western US) commonly needs some point of entry. This is even more true when researchers want to study a vulnerable population and are themselves outsiders.

In our case, we could not rely on a politically oriented or community group of “stigma sharers” because the few that do exist are oriented around fat acceptance and “Health at Every Size” goals. We wanted to talk to people who internalized fat stigma and felt it was making their lives miserable, rather than the more studied proponents of the fat acceptance movement. We also wanted to talk to people who knew what it was like to live with fat and live without fat, medically and socially. At a time when medical, public health, and media commentary tends to make it sound like the entire planet is careening toward an “obesity epidemic” (the terminology most often used), studying a group of people who have experienced the reverse trend (extremely fat to not fat) in a fat-stigmatizing context like the US can give us insights into both the experience of unwanted physical weight and its emotional, moral, and social implications.

These considerations meant that the bariatric clinic was an excellent point of entry. However, it took a substantial amount of both administrative approvals and one-on-one relationship building to convince clinicians, who in this case understood the sensitivities and vulnerabilities of their patients, to trust us enough to fully engage in long-term participant observation and patient recruitment within the clinic. Alex spent two years prior to the study launch building trust with hospital administrators. Sarah and Alex talked to most of the bariatric providers and clarified the details of the study before the study began. Sarah provided similar explanations to preoperative and postoperative patients in meetings of the bariatric support group and the behavioral change classes on a routine basis. All three of us went through a variety of quite complex and time-intensive research clearances at the clinic and our own research institution.

One of our goals was to track the patients’ changing understandings of their bodies as they lost weight postsurgery. This required a longitudinal (over time) design. The study incorporated repeated interviews of the same set of thirty-five participants, all of whom were at different points in their pre- and postsurgery trajectories. We also conducted two years of clinic-based participant observation in the public spaces of the clinic, focused on interview participants who were patients, patients who did not participate in the interviews, and health-care providers. Lastly, we sent out two waves of surveys (spaced a year apart) to the entire hospital bariatric-patient pool, with a survey sample size of three hundred. Our methodology was thus a technically and practically complex one. The administrative side demanded constant relationship management at high levels. The data collection required highly consistent interviewing styles maintained over time. The analytic methods demanded high levels of technical expertise. It was a large job for the three of us to collect and analyze the array of data with the consistent quality needed, while maintaining the necessary multilevel clinic and participant relationships that allowed the study to continue successfully to its conclusion.

For us, working collaboratively was intellectually and emotionally rewarding, and this helped counter many of the practical and ethical difficulties associated with the project. Now, many years after we first started building our recruitment methodology, we doubt the study could have succeeded if it followed the more traditional approach of a single anthropologist managing all aspects of the study. A team approach made possible the sheer volume of labor involved in managing the complex politics of working in the hospital structure, the fieldwork within the specific clinic with both staff and patients, and the volume and complexity of data our study produced.

It was also helpful that all three of us had our own extensive prior ethnographic experiences, each having conducted long-term field projects in very different places. We had all experienced field research gone wrong, where community relationships were compromised by misunderstandings or miscommunications. We had implemented multiple ethnographic methods many times previously. As a result, we were not learning how to implement various parts of a collaborative, multiyear project on the fly as we rolled the project out. Working in a high-profile, highly regulated clinic means there is not a lot of room for error or do-overs: a serious error and we would have lost access to patients and staff. We have provided details of the methods we deployed in this study in the appendices, for those who are interested in how we went about data collection.

Our particular three-person ethnography in a clinic produced two major interpretive limitations, however. The first has to do with us as individuals. One of the major critiques of social science studies of stigma is that many studies are conducted by people who do not have insider status with the group being studied; in other words, they do not share the vulnerable trait. In this case, none of us have personally experienced extreme obesity or gone through bariatric surgery. Our perspectives are built on multiple years of carefully listening to people who have experienced both of these embodied states, but we have not lived/embodied them ourselves. Sometimes—given rampant fat stigma across many sectors in the United States—this has proven to be an advantage in our work. In certain settings, we are perhaps given more credence than we would be if we were read as fat people (just think of the uphill battle obese physicians face with regard to respect from patients and other providers). At the same time, however, our “outsider status” almost certainly affects what people do and do not feel comfortable sharing with us. Our findings should be tempered with this understanding.

The other interpretative limitation stems from the particular nature of our relationship with the clinic. As was hopefully obvious in our earlier descriptions of our relationship building within the clinic, in order to conduct research within this space, we had to adhere strictly and revert consistently to the authority of clinic rules and norms. There was little space for negotiation over the form of the social science research in which we were involved, compared to what we have previously experienced working within nonclinical settings. Our human-subjects research application (which any US-based researcher who wants to conduct research on humans must submit in order to be in compliance with current international ethical standards) went through the clinic’s review process first, before our own institution would even review it. This oversight was ethically and pragmatically necessary, but it did impose certain restrictions on the degree to which we could ask critical questions within clinical spaces. For example, once question sets for interviews were approved administratively, we could not then follow emergent ideas in new directions to the extent we are able to do on other ethnographic projects. Similarly, basing ourselves in a clinic meant that some of the boundaries of the clinic-patient relationship also applied to us. If a patient dropped out of the clinical program, for example, we tended to lose sight of them as well. This was particularly frustrating in some cases but does help to explain why data on the postoperative lives and health of bariatric patients in the long term, more than five years after surgery, is lacking more generally (although there are exceptions).21

Finally, we feel it is important to note that as ethnographers, our overriding ethical commitment in any project we undertake, whether individually or as a team, is to depict the cultural worlds of our participants in a way that does them no harm. Because they were bariatric patients, most of our participants had suffered a great deal of stigma and social devaluation, and we therefore felt this duty especially strongly on this project. Although we are well aware that other theoretical lenses, including a critical lens, could be applied to our research, we have opted not to do so ourselves. Instead, we provide enough ethnographic depth and rich description to support alternative readings and leave such analyses in the hands of the reader.