In a CBS News interview last year, Robert F. Kennedy Jr., the health secretary, offered a little parable about American sickness. “If you want to eat doughnuts all day or drink sodas, that’s your choice,” Mr. Kennedy said, before musing, “Should you then expect society to care for you when you predictably get very sick?”
This was not an isolated flourish. In an event in West Virginia last March, Mr. Kennedy mocked the governor’s weight and asked the crowd whether the governor should do a monthly “public weigh-in” until he lost 30 pounds. Mr. Kennedy has suggested that the obesity epidemic could be solved with three good meals a day, while disparaging evidence-based interventions like GLP-1s, suggesting that the company behind Ozempic and Wegovy is “counting on selling it to Americans because we are so stupid and so addicted to drugs.”
Mr. Kennedy’s remarks hark back to a time when obesity was treated less as a chronic disease and more as a failure of willpower. Gone was any notion of body positivity or “health at every size”; back in was a language of blame, discipline and deservedness.
To Mr. Kennedy’s admirers, this is not cruelty but moral clarity. To most public health officials, though, it is a dangerous anachronism.
“We’re seeing an impressive resurgence of some of the stigmas that we felt perhaps we were doing better about,” said Allan Brandt, a historian at Harvard Medical School.
Over the past few decades, public health has grown suspicious of and moved away from harsh, virtue-laden messaging. But Mr. Kennedy’s leadership suggests that the turn toward destigmatization has provoked its own backlash — a belief that compassion has become coddling and that structural explanations — food deserts, for example — have crowded out personal responsibility.
At the center is an old assumption: Stigma, however harsh, is a form of medicine. Is it?
How Public Health Shunned Stigma
In 1963, the sociologist Erving Goffman put forward one of the most influential definitions of stigma. He called it a mark of social disgrace, reducing someone “from a whole and usual person to a tainted, discounted one.”
Researchers have since refined this idea, framing stigma as a complex, multilevel process. It begins when some difference is labeled and loaded with stereotypes, eventually hardening into a distinction between “us” and “them.” The result can’t just be hurt feelings; stigma, by definition, must lead to status loss and discrimination, said Mark Hatzenbuehler, a psychologist at Harvard University and director of the Biopsychosocial Effects of Stigma laboratory. In other words, stigma is an exercise of power.
For much of the 20th century, public health employed stigma liberally in the United States, Dr. Brandt said. Women suspected of having venereal disease, for example, were arrested, forcibly examined and confined in reformatories, as if infection proved sexual corruption. In the 1950s, fatness was described as a mental illness, and people with obesity were cast as undisciplined and burdensome.
And with the anti-smoking campaign, stigma seemed to have its big success story. People who used tobacco were increasingly depicted as selfish and dangerous to others, and smoking rates fell In 1964, 42 percent of people in the United States smoked. In 2024, 10 percent did. To many, the lesson was obvious: Stigma works.
The reality was more complicated. Rising taxes and indoor smoking bans shifted the practical calculus, while people who successfully quit pointed to concern for their health and a desire to set a better example for their children.
Because there was a lethal, addictive product and a clear corporate villain, fear campaigns played an important role in warning people about the dangers but then offering a way out through cessation support, said Amy Fairchild, a historian of public health at the University of Minnesota. But when this fear tipped into stigma, going so far as to disparage smokers, it undermined the public health effort, Dr. Brandt added. Later research, for example, shows that stigma is tied to more attempts to stop smoking but less success actually quitting.
That made tobacco a blurry lesson about the efficacy of stigma, but AIDS made the dangers far harder to mistake. A mysterious, often fatal disease was spreading through sex, blood and needles — particularly among gay men and people who used drugs — and Americans needed to know the risks.
But in many cases, public health turned this truth into images of contamination, intensifying the marginalization of already vulnerable groups, said Lawrence Yang, a psychologist at Duke University. For example, in 1990, the Centers for Disease Control and Prevention ran ads like “If you shoot drugs, stay away from me” — not warning against shared needles, but casting the person who injected drugs as a source of danger.
People with AIDS, in turn, were abandoned by families, fired from jobs, refused medical care and, in many states, criminalized for having this disease. By the late 1980s, about half of Americans surveyed by Gallup believed people with AIDS were to blame for their own illness, and many thought the disease was “God’s punishment.”
Over time, public health authorities learned that stigma wasn’t containing the epidemic but helping conceal it. Some people avoided testing to avoid the shame of a positive result. Others, fearing rejection and discrimination, kept their diagnosis secret and avoided health care. Public health campaigns that tried to bring risk into the open taught people to go underground instead.
By the end of the 20th century, stigma had lost much of its legitimacy, Dr. Fairchild said, and anti-stigma work started to become a public health project of its own. There were education campaigns for mental illness, substance use and disability, as well as language guides, bias trainings and an emphasis on social determinants.
This shift took longer for obesity, said Rebecca Puhl, a psychologist who studies weight stigma at the University of Connecticut. But in 2013, the American Medical Association recognized obesity as a disease, while the C.D.C. encouraged person-first language (“adults with obesity” rather than “obese adults”) in 2020.
Stigma had become a problem to eliminate, rather than a tool to deploy.
Beyond Blame and Coddling
But the evidence against stigma’s efficacy, Dr. Hatzenbuehler said, should not be mistaken for evidence that destigmatization has generally succeeded. Perhaps at some level, the backlash that Mr. Kennedy represents is responding to a real weakness in anti-stigma work.
Dr. Puhl argues for a framework of “constructive responsibility,” which acknowledges that individuals do have responsibilities but insists that industries, policies, and environments must also be held accountable. That way, the “burden of sole responsibility” does not fall on the individual.
This framework resists a simple binary. Of course, people can lose weight by changing what they eat, moving more and going into a calorie deficit. But it’s also true that a vast majority of people who lose weight this way regain it over time in the face of biological and environmental factors beyond their control. Constructive responsibility does not discount the importance of choice, but rather recognizes that choices are made within systems that either support or impede change.
Americans seem to hold both truths at once. According to a February poll, they see obesity as a disease and recognize the role of ultraprocessed foods, while still wanting solutions that leave room for personal effort.
Stigma, though, may not be the right tool to strike this balance. Research has consistently found that stigma strips people of social support and drives them to conceal their illness and avoid care. As stigma becomes internalized, it turns a person “into his own jailer, his own chorus of denunciation,” wrote Scott Burris, director of Temple University’s Center for Public Health Law Research. People often assume that shame pushes someone toward better choices; however, research suggests that it more often loads people with stress, Dr. Puhl said, making them less likely to engage in healthy behaviors.
But if stigma individualizes responsibility, much of anti-stigma work to date has made a mirror-like mistake, addressing the problem at the individual level, Dr. Hatzenbuehler said. In general, this work has treated prejudice as something lodged inside a person’s mind, even though stigma is socially and culturally inculcated. “You’re pulled into a training and told that you personally are responsible, or this is a moral failing, when, in fact, this is water that you’ve been swimming in,” said Betsy Paluck, a psychologist at Princeton University.
In a 2021 review of more than 400 experiments to reduce prejudice, Dr. Paluck found that, on average, they had little effect. Most approaches were “light touch,” like brief trainings, videos and perspective-taking exercises, and the largest, most robust ones reduced prejudice by just four points on a 100-point scale. “It’s not going to result in a noticeable behavioral change,” Dr. Paluck said, adding, “our solution has not fit the problem.” In fact, when anti-stigma interventions treat prejudice as a personal defect rather than a social pattern, invoking guilt or shame, they can backfire, increasing bias compared with doing nothing at all.
The alternative is to move from instruction to infrastructure. With H.I.V., for example, advocates and public health officials changed the meaning of the disease, transforming it from a death sentence into a condition managed with medication, and pushing legal and policy changes that improved access to care and reduced discrimination, Dr. Yang said.
Obesity has not seen the same move from attitudes to rules. In almost every state, for example, you can be denied work or fired because of your weight, aside from Michigan, which has banned weight discrimination, and Washington, which protects obesity under disability law. Anti-stigma work shouldn’t just ask people to be kinder but change the laws and institutional practices that keep stigma in place, Dr. Puhl said.
Similarly, it should change where the blame lands. Researchers found that antismoking messages focused on industry deception — like how Big Tobacco targets teens or manipulates the public — were some of the most effective at reducing cigarette consumption.
One could imagine a similar re-orientation for the anti-obesity campaign, focusing on the companies that flood the food chain with cheap, addictive products. In fact, research has found that the most motivating anti-obesity messages did not mention body weight at all, Dr. Puhl said, but focused on eating behaviors and the food environment — what people were being sold, served and surrounded by.
In that sense, Mr. Kennedy is pointing to something real when he attacks the food industry and other commercial drivers of the chronic disease epidemic. For example, he has said that the obesity crisis didn’t happen because Americans suddenly became lazy or developed large appetites, and he’s noted Big Tobacco’s role in steering the food companies in the 1980s and ’90s, engineering their products to be addictive. “Everybody has the capacity to be thin, to not smoke, to exercise extensively, to eat the right foods. Given the fact that you have agency and you’ve failed, you are to blame,” Dr. Brandt said, sketching out that logic.Mr. Kennedy has condemned the system but has also cast the people shaped by that system as irresponsible.
Public health has long struggled to navigate between undermining people’s agency and shaming them for failing to overcome rigged conditions. That tension hasn’t gone away.
Simar Bajaj covers health and wellness for The Times.
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