“A reflexive, relentless interrogation of common sense”: Emily Yates-Doerr on anthropology, global health, and obesity

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Grace Fletcher

Grace Fletcher

Grace Fletcher is a candidate for the MPH in Global Health & MA in Latin American Studies at Vanderbilt University. She works at the intersection of social science and global health and is interested in research, M&E, and program improvement, especially in marginalized Latin American communities. She is the Editor of the Global Health Hub. @grfletcher07

Emily1Emily Yates-Doerr is a Veni Laureate and assistant professor of Anthropology at the University of Amsterdam. She currently is studying a United Nations initiative to improve human capital through nutrient supplementation over the “first 1000 days of life.” She has been carrying out ethnographic research in Guatemala since 2000. Her book, The Weight of Obesity: Hunger and Global Health in Postwar Guatemala (2015), is available from the University of California Press. We recently chatted about her new book and her continuing research on nutrition and obesity in Guatemala.

 

Tell me a little bit about the work you’ve done around obesity in Guatemala. What drew you to this topic?

I started working on this project in 2004 as part of my doctoral work in anthropology. I was working with a group of forensic, physical, and cultural anthropologists to chart the emerging discussions of what was being called “globesity” – this was a really new idea at that time. I returned to Todos Santos, which is a Mam-speaking highland village community of Guatemala. There, the town center had been remodeled, and there was a gigantic Coca-Cola sign on it, and thinking back now, this ad was kind of a catalyzing event for me.

The remodeled town center of Todos Santos, complete with advertisement for Coca-Cola.

I saw a lot of changes that were underway in the dietary landscape. You had NAFTA [the North American Free Trade Agreement] that was changing the kinds of foods that were showing up in Guatemalan marketplaces, and then CAFTA [the Central American Free Trade Agreement] in 2006. And so political scientists were studying the growth of transnational grocery stores like Wal-mart and epidemiologists were tracking the rise in NCDs and health workers were beginning to organize classes on obesity prevention.

But accompanying these changes in food ecologies was also this proliferation of information about the importance of weight loss. I was routinely told by public health experts that Guatemala’s indigenous and poor populations didn’t understand how to eat, that “they think fatness is healthy.”

And so the book is based on that interest in these collisions, how these different ideas of fatness are unfolding in everyday life. I think of my study as less of representing the beliefs of a particular population—the idea that this is a “cultural problem”—and more of an ethnography of the diagnosis of obesity.

So, although obesity was relatively easy to define in theoretical terms, (eg. a BMI of over 30), translating this into practical or clinically meaningful terms was a really imprecise process. I think that part of the story is that the logic that works for epidemiological science may not hold that up that well in clinical practice. But when there aren’t funds for substantial clinical care, then you get an epidemiologic logic taking the place of a care logic.

Can you give me an example of these collisions between epidemiological, clinical, and practical understandings of obesity?

The scales that we used in the clinic where I did a lot of observation were wobbly and pretty old. Patients had to step up onto this platform and then they had to hold still, which wasn’t that easy to do, especially since they were often seeking treatment for dizziness or joint pains. So the nutritionists sometimes wouldn’t let go of patient’s hands when weighing them.

Scale

Rickety scales in an obesity clinic.

The scale, rather than providing a measurement of the individual’s weight, was a technology that could facilitate that first collaborative exchange between nutritionist and patient. So something as obvious as the measure of weight was full of a social life with unpredictable, unexpected effects. In the logic of the BMI, the number that results is a measure of whether you are healthy or not. But in clinical practice, it was an occasion to begin to build rapport.

That’s a nice illustration of this idea of the social life of the things that we measure. I think that many people who work in global health are really almost obsessed with the idea of measurement, but it sounds like what you’re suggesting is that there’s so much more that goes into these measurements, and that’s the part that is interesting and important to the outcomes that we measure. Is that fair?

Yes. It’s related to what I write about in the book about the shift from medicalization to metrification. Medicalization is the idea that aspects of life that were once not medical in nature have now taken on medical authority. Eating is an example—what was once pleasure, now you eat for health. But the story in which medicine is this strong and powerful institution just didn’t seem to work very well in Guatemala where people were routinely lamenting the weakness or absence of medical care, and would point all the time to wanting more, and not fewer, public health services. Metrification may be a more accurate descriptor of the changes that were underway. And by that, I mean the attempt to transform just about everything into a measurable number. Eating, moving, breathing, life itself.

Do you feel like the nutritionists you were working with had any ability to go beyond the metrification?

Many of the nutritionists were really committed to suggesting dietary changes instead of medications. At the same time though, they were finding that in the clinical setting, there’s really little that you can do to address structural inequities in the food supply, and work conditions that feed into the kind of illnesses that they were there to treat. So, they would very often turn obesity consultations into therapeutic spaces. So it was just a chance for people to talk about hardships, rather than a chance to receive expert advice on what to eat. So instead of talking about food at all, we would often talk about husbands’ immigration to the US, children’s unemployment, or precarity in living without health insurance. And I can partly credit the nutritionists for making me ask, what is obesity outside of the clinical setting?

Traditional Guatemalan dishes being prepared in a market.

For example, people’s notion of gordura, or fatness, entailed so much more than weight. Fatness could pertain to abundance, or happiness, or richness in life. It wasn’t to be measured, and even if it was to be evaluated, it was an evaluation that wasn’t based on measured standards, but on relational knowledge of someone. So to say that someone was fat was to say their life is going well, and to say that you had to know something about their life. So then people weren’t wrong in holding fatness to be healthy, they were just working with different approaches to evaluation and different priorities in health.

Patients would come in wanting to lose weight, but the nutritionists would work to shift their attention toward what they might be able to do in order to regain their sense of abundance. So they would ask, how can you become fat again in your life? And this wasn’t a question about how can you gain weight. It was really a question that worked to move away from metrics to focus on the context of eating. And obviously there are a lot of limitations to what one person can do to change their eating practices, but I found that the opposite of obesity wasn’t thinness, but fatness.

Do you feel like this reframing by the nutritionists made a difference?

It shifts the target. So instead of the target being weight loss, because it’s really hard to lose and maintain weight over time, we shift the target away from something that is almost going to be a failure before you begin, to something that  may perhaps be achieved: can you eat with your family? can you enjoy your food? It changes the conversation, and I think that that perhaps can make a difference.

That makes sense. Although I have to tell you, I can hear the public health obesity expert shrieking in the background, “But, how do we actually do that?! How do we know if the intervention is working?!”

This is one place where anthropologists really have reality on their side, because the existing strategies do not work. I think that is one of the reasons that there’s interest in working collaboratively with anthropologists, and opening up the conversation beyond metrics to anthropology. Because the kinds of things that are in place right now, even on their own scale of efficacy, are not working.

Could talk a little bit more about how you think anthropology, or the social sciences more broadly, are important to global health?

I think that a lot of times, collaboration comes from the idea that you have to start from common ground. Global health can be really good at compressing difference into a common ground; that’s what a metric can do. But I think that anthropology can open up the possibility of different starting points for collaboration. You can start from places of difference. You don’t necessarily need to begin a conversation from common ground, but you can begin a conversation by just saying, listen, we do slightly different things here, so how can we bring them together?

La Democracia market, in Quetzaltenango, Guatemala

I think in anthropology there’s been a push toward moving away from just a critical stance. There are all kinds of problems that we can really collaborate on with the field of global health. Furthermore, I think it would really be a shame if anthropologists thought that it should only be about ethnographic methods, because what we need is a bunch of different methods.

So in some ways I’m really in alignment with classic attention toward structural violence, that points out how some, usually poor, usually brown, often female gendered bodies are systematically disenfranchised. But, that said, I’m also made uncomfortable by the idea that one can know by looking at, or measuring someone’s body whether she is healthy or not. And the global health community commonly describes the prevalence of fat brown people as evidence of structural violence. I try to show that this automatic link between fatness and illness, this thinking that you can know someone’s interiors by looking at their measurements, puts an ontological violence over a structural violence. So I think in some ways, maybe the aim there is to help global health do a better job with the resources that it has. And so I hope in some ways that the ethnographic contribution is that we can pay more attention to these other ways of knowing health and other ways of knowing the body as well.

Is there one thing that you think would be important for people working on the ground around issues of obesity and nutrition in places like Guatemala to understand, based on the work that you’re doing?

I actually started as a biologist. One of the reasons I moved from biology to anthropology was because I really like the field of anthropology’s reflexive, relentless interrogation of common sense. I think that anthropologists can be really good at listening carefully to others and producing rich and influential knowledge about the world. People in the public health community also know this. But whenever we are too comfortable in thinking that we know what we know, that is a really good chance to listen to what else is going on in the world, because very often our own common sense doesn’t mesh well with reality. So anytime I’m a little too comfortable in thinking that my categories are the right categories, it’s often a time to listen to the categories that are at work and the way that the categories around me are being assembled.

This interview has been edited for length and clarity.