In Some Cultures, a Role for Shame in Addressing Obesity?
In the Cook Islands, a physician is changing a culture that sees some of the highest rates of obesity in the world. Some of his methods are inappropriate by American standards, but effective.
According to the Ministry of Health, 87 percent of the population in the Cook Islands is obese. The World Health Organization recorded rates of obesity as high as 75 percent in Nauru, Samoa, American Samoa, the Cook Islands, Tonga, and French Polynesia. According to the 2011 report, "The factors for this epidemic of obesity are a dramatic decrease in physical activity and a dependence on Western diet."
Most reports cite the need for a return to a local diet and more exercise. They do not address the barriers, psychological and practical, to behavioral change.
How do you get a Pacific Islander who, thanks to WWII, loves canned corned beef, Spam, and rice, to start eating arugula?
While I was living in the Cook Islands, I met a clever doctor working specifically to combat obesity and its related consequences. His patients were losing weight, but his methods were far from typical by U.S. standards.
Dr. Hla Thein grew up in Burma and was educated, as are most young men, by monks. He learned English at a young age, went to medical school in Rangoon. He worked for the United Nations in Thailand with refugees from the Khmer Rouge and eventually settled in Fiji. He explicitly wanted to combat obesity, diabetes, and hypertension in the Pacific and moved to the Cook Islands to do so. He took a post that no other doctor wanted and moved to the isolated atoll of Pukapuka with a population of 450. On the three square-kilometer atoll, boats come only once every six months and planes only on government business. "Here," he says, "I have the perfect laboratory to combat obesity and associated non-communicable diseases."
Thein started by approaching diet. Pukapukans in general eat healthy with a daily diet of fish and taro. But reliance on imported foods, primarily canned corned beef, sugar, flour, and rice has steadily increased. Most Cook Islanders have spent time in New Zealand and Australia, cementing a love for KFC and McDonald's. In order to promote the local diet over the imported diet, Thein did not lecture or educate. Research has shown that education does not create behavioral change, especially in the early stages. People may know the facts but they exempt themselves from the consequences.
Instead, Thein used methods congruent with the community. To set an example, he started a garden at his home -- planting cucumbers, lettuce, bok choy, and watermelons. He gathered all the hospital staff, nurses, and even the local dentist to assist in the building of his massive garden. At first, this seemed a strange use of hospital work time. Soon, however, villagers came and gathered to watch the hospital staff gardening. Children began asking for seeds. Before long, everyone had started a home garden. The gardens didn't last because of the salt spray, the sandy soil, and lack of regular access to seeds, but the seed had been planted. People wanted to eat cucumbers.
Thein then called the island leaders together and asked them to prepare a feast using only local ingredients. He only showed up to eat, saying little. He let the villagers take charge of preparing and presenting the local feast, which included coconut crabs, coconuts, pumpkins, fish, and taro leaves.
He also started shaming people.
Shame and ridicule are actually common ways to regulate behavior in small Pacific Island communities. He regularly said to his patients, "There is something wrong in a place where the parents are so fat and the children so skinny." He started monitoring what parents gave children for school lunch and posting it on the government notice board for everyone to see, and laugh at. Pretty soon shamed parents fed their children baked uto (sprouted coconut) instead of packaged instant noodles. This also meant that the parents ate the same healthier cooked food, and in smaller portions.
Many mothers in the Cook Islands feed their babies a bottle of warm water with two teaspoons of sugar, a path to diabetes. Dr. Thein refused to treat the infants or mothers if they fed the baby sugar water instead of breast milk or formula. He also made jokes about the "ugly babies" fed on sugar water bottles. His litany of shaming jokes was just part of how he operated.
In terms of exercise, he encouraged it but mostly he modeled it. Every morning and every evening he would walk around the island with his wife at a brisk pace. He stopped and visited as he walked, often asking, "What are you having for dinner?" He might then mention how canned corned beef causes premature ejaculation, to huge eruptions of laughter. Then he would continue walking.
He used these tactics implicitly, not just with obesity, but with all health care. When a married man came in with a sexually transmitted disease, he refused to treat the man until the man returned with all the partners that he had slept with. Despite his shame, the man had no choice but to bring all the women in for treatment too. He allowed the teenagers, embarrassed about sex, to come to his home in the safety of the dark to request condoms.
Dr. Thein did not lecture. He did not educate. His garden spoke for itself. And so did the public notice board. His jokes entertained and ridiculed. While not politically correct, these methods worked for the community. He showed that changing behavior depends, in fact requires, adapting to the culture.
He did not attend cross-cultural seminars on behavioral change. He knew rural and Pacific Island communities based on his own life and used this intimate knowledge, and he knew what would work there.
Against the backdrop of rising obesity rates, we have begun to seriously talk about prevention and the challenge of behavioral lifestyle change. Dr. Thein doesn't know how to turn on his shiny black Android tablet, but he knows the rhythms and the culture of the community he works in. Before we make blanket assumptions about what is or is not a proper approach to obesity, we must consider that cultural context can make all the difference.