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Global Obesity

As obesity goes global, interdisciplinary Duke scholars study the social, political and economic influences

Weight is a moral force, said medical
anthropologist Harris Solomon. In his research on obesity, he aims to
complicate the questions, rather than risk missing important issues by
oversimplifying. "Who has the authority to tell you what to eat, how you
enjoy it, how to be healthy? Why is there a certain ideal thin body that we
should all aspire to, and how is that getting circulated globally?"

Newly appointed to a joint
assistant professorship
with Duke's cultural anthropology department and Duke Global Health Institute (DGHI),
Solomon said the language we use to talk about a problem and the context in
which we frame it can sometimes obscure the real problems and lead frontline
medical workers to erroneous conclusions. Nobody makes moral judgments about an
arthritis patient. But when it comes to people with diabetes, high blood
pressure and other chronic ailments associated with obesity, insinuations of
personal responsibility color the discussion.

Solomon studies the
relationship among food, health and consumerism. He was drawn to Duke by the
university's reputation for interdisciplinarity.
In understanding global health, ethnography -- the science of
contextualization -- can be a powerful element to drawing accurate conclusions and
forming effective solutions, he said.

While in India, which in
recent years has shown a rise of epidemic proportions in diabetes and
cardiovascular illnesses related to obesity, he noticed a number of weight-loss
clinics opening up and advice columnists writing about how to lose weight. This
implied that the cause of obesity and its related illnesses could be pinned on
individual behavior. Solomon questioned such a simple dispatch of the problem.
The story of the rise in obesity rates needed context before researchers could
come up with solutions to this health issue.

"Cultural
anthropology offers a compelling vocabulary for how we talk about disease,"
he said. "It can show us where other possibilities might lie that we haven't
talked about. Ethnography has a natural and critical place in our thinking
about the connection between culture and health. It's an essential and integral
part of how we deal with the global health problems of our generation."

Orin Starn
Orin Starn

Orin
Starn
, chair of Duke's cultural anthropology department, underscored the
importance of a multidisciplinary approach to solving societal problems.

"Weight is a modern
obsession, and it's also a social, cultural and political issue that has to do
with how much money you have and what you can afford to put on the table, with
changes in commercial agriculture and fast food and other changes in global
culture," Starn said. "Harris's work is showing us how this is a
really complicated set of questions that we need to think about."

Cultural anthropology and
global health interest overlap, Solomon said. Both disciplines take on similar
issues but approach them from different methodologies and theoretical
perspectives, he said. "Having an open door between cultural anthropology
and global health, and having a conversation about why culture is important and
what is this culture we're talking about, opens opportunities for discussions
about complex questions."

The language of the
discussion was the portal for Solomon's career in medical anthropology.

Originally from Florida, Solomon went to Northwestern University for his
undergraduate degree in linguistics, which he completed in 2000. As a student,
he worked on a project that studied the ways people talked about HIV. He
developed an ear for the connections between language and medicine, and an
interest in health policy. He immediately went on to acquire a master's degree
in global health from Emory University in 2002. For the next few years, he
worked on HI V policy in Atlanta and Washington, D.C. His work took him to
India frequently. In addition to tackling global health issues of HI V and
AIDS, he examined access to health care and the practice of medical tourism,
where patients travel to India from other countries to receive high quality
health care at a lower price.

The research projects he worked on
left him with pressing questions about the context of the stories he delved
into, and he went back to school, this time to Brown University for his
doctorate in cultural anthropology. To conduct the research for his
dissertation, he moved to India for a year and a half.

Solomon studied the idea of "globesity"
as one way of framing the epidemic of obesity-related chronic illnesses in
India. China, too, in recent years has shown a similar rise in obesity and the
health problems that go along with it. Putting the blame solely on individuals
doesn't tell the complete story, he said. The crossdiscipline conversations he
has in his joint appointment help to complicate questions to reveal the whole
story.

"Ethnography can be a powerful
element in understanding global health," Solomon said.

While living in Mumbai, he saw the incredibly
polluted water and heard residents complain universally about the poor quality
of the water. "I couldn't help but think that the polluted water might
have some biological effect on metabolism sensitivity that might at some point
manifest itself as a precursor to diabetes or obesity," he said. He
learned that Indian bioscientists were having similar conversations in their
own research projects. (Another attraction Duke held for him was research in
metabolic science conducted at the medical school.)

Harris Soloman

Harris Solomon at a Durham Indian food market.  Photo by Megan Morr/Duke University Photography

But simplifying the health issue to
put the blame on the individual erases the story of environmental hazards,
Solomon said. Another example comes from popular media circulating the story
that attributes weight gain to the middle classes in India eating more
packaged, processed food, following a trend in Western diets. The media portrayed
the practice as middle classes striving for modernity through food. Solomon dug
deeper into the issue and learned that many people in his neighborhood in India
were eating packaged foods more frequently because of their concerns over food
adulteration. Bulk foods at the traditional markets had a greater risk of being
tainted. People bought packaged foods to reduce their chances of getting sick.

"The story of globesity gets told
as America exporting fat," he said. "It's a very problematic
generalization about the relationship of the U.S. to the rest of the world,
that of all the things we could share with the world, we share unhealthy
bodies."

In examining the rise in the number of
obesity-related diseases, many other factors come into play: food pricing, what
people can afford to put on their tables; food distribution, what is available
to buy; malnourishment, which can trigger metabolic changes to favor gaining
weight; and changes in the health-care landscape that determines who has access
to preventive care.

"My interest is to do descriptive
and analytical work," Solomon said. "My research tries to capture the
nuances of the story. I'm interested in adding a cultural and political
conversation to clinicians' conversations at the cellular and clinical level."

If researchers limit themselves to an
American perspective, the problem can be distorted all the more, said Starn.

"In American culture, there's a
premium on the individual and self-help and taking charge of your life,"
Starn said. "Weight gain has been stigmatized as a moral failing of the
individual. Overweight people are one of the last remaining groups in the U.S.
that it's OK to discriminate against."

This fall, Solomon is teaching a
course in medical anthropology through the cultural anthropology department. In
the spring, he'll teach a course he's developing for Duke Global Health
Institute. He'll alternate teaching in both areas, serving as a link that will
keep the cultural anthropology department and DGHI faculty aware of mutual
interests in each group, said Randy Kramer, deputy director of DGHI and who
holds a joint appointment as a professor of environmental economics at the
Nicholas School and of global health at DGHI.

"Anthropology helps us understand
health behavior and how culture shapes that behavior," Kramer said. "India
is very important to the Global Health Institute. It has a number of
significant demographic and economic changes going on that translate into
important health disparity issues that need careful examination."

Students, some of whom are completing
their Global Health Certificate or are interested in global health-related
careers, benefit as well from joint appointments.

"Because Harris has lived in
India while doing his dissertation research, he brings those experiences into
the classroom," Kramer said. "That cross-cultural knowledge is really
important in the study of global health."

With the dual perspective, students
see culture in a different light: not as a problem to solve, but as something
that infuses the problems and possibilities of global health. Duke's President
Brodhead promotes the idea of knowledge in the service of society, and joint
appointments support that mission by broadening students' perspectives. It's
very easy to lapse into thinking that global health is a challenge only in
countries outside the U.S.

"Health disparities are absolutely
in plain sight in Durham," Solomon said. "Problems are endemic here
around insurance coverage, access to health facilities, the high prices of
pharmaceuticals, health social services for minority and immigrant communities."

Solomon wants to ensure that Duke
students, whatever their field and wherever they go, will make the problems
they are trying to solve more complicated.

A Moral
Force

Solomon spent the past several years
watching snack food sellers in Mumbai, hanging out with Indian mothers as they
cook for their families and interviewing Indian companies that have begun using
healthier ingredients to promote their foods to consumers worried about their
waistlines.

"Obesity is so interesting to me,
since food is morally charged," said Solomon, who argues that consumerism
and modernization alone cannot explain India's problems with obesity and
related illnesses such as diabetes. "Some people have blamed overindulgent
parents or the growing number of people with sedentary jobs, but the issue is
more complicated. We need to ask who puts food in circulation. How is it
priced? Who has access? You can't just frame obesity in terms of personal
indulgence or a society becoming wealthier."

In
his own research,
Solomon focused recently on street vendors who sell a
Mumbai specialty called vada pav, a
spicy snack that looks like an Indian hamburger. The "desi burger,"
as some describe it, is important not only economically and nutritionally, but
also for the insights it offers about how people think about food and politics.

Much like India's growing number of
neighborhood diet clinics or its advertisements featuring women who have become
trimmer in recent years, a humble snack food can illustrate why "biomedicine
is not the only way to talk about health and illness," according to
Solomon, who said "public health debates offer a lens into Indian society."