Critical perspectives on wellness.

Journal of Health Politics, Policy and Law

Critical Perspectives on Wellness Anna Kirkland University of Michigan

Abstract Workplace wellness programs are written into law as exceptions to otherwise protective antidiscrimination provisions, and the Patient Protection and Affordable Care Act expands employers’ ability to treat workers differently based on their health. Rather than assume that wellness programs promote health and save money, here I approach them as legally sanctioned discrimination. What exactly wellness discrimination might look like in practice across many contexts is an open question, but there is good reason to be wary of the power of wellness to create and reproduce hierarchy, to promote homogeneity, narrow-mindedness, and moralism about how to live one’s life, and to cover for discrimination based on health, weight, income, age, pregnancy, and disability.

Introduction: Treatment on the Basis of Wellness as an Exception to Antidiscrimination Law

Wellness has been around for a while now, and critiques of wellness are not entirely new. The sociologist Peter Conrad observed the tendency of workplace wellness initiatives to be moralistic forms of corporate social control a quarter century ago (1987, 1988, 1994). Similarly, Howard M. Leichter (1997) characterized the ‘‘lifestyle correctness movement’’ as ‘‘the new secular morality’’ over fifteen years ago. Nonetheless, some features of today’s wellness program landscape deserve reexamination. While wellness has consistently focused on individual maximization of functioning since the coining of the term (Dunn 1961), at the beginning of the contemporary resurgence of interest in wellness in the 1980s and early 1990s it was a much more capacious concept that was not so centrally fixed within Journal of Health Politics, Policy and Law, Vol. 39, No. 5, October 2014 DOI 10.1215/03616878-2813659 Ó 2014 by Duke University Press

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the workplace and our employer-based health insurance system. Over the past several decades, the meaning of wellness has narrowed and been institutionalized by private employers in the United States into what I call workplace wellness or corporate wellness. I focus on employers who offer health plans to their employees because they are the site of both recent policy changes and substantial growth in wellness programs, although these employers may not be for-profit corporations. Wellness programming has become an important part of the workplace in higher education for both students and employees, in nonprofits, and also within municipalities (reaching beyond employees to the whole citizenry, as in Massachusetts’s ‘‘Mass in Motion’’ statewide wellness campaign, run by the state’s Department of Public Health and aimed mostly at obesity reduction [EOHHS 2014]). Some of the problems I identify here are specific to an employment setting, such as hiring or firing based on health status, but my suggestion that something is troublesome about the hierarchy and uniformity created in wellness culture would apply to noncorporate settings and would raise the same questions for the effects of wellness promotion on equal citizenship, for example. The most important recent development has been the elevation and promotion of workplace wellness programs within the Patient Protection and Affordable Care Act (ACA) and its creation of an exception to the nondiscrimination provisions of the Health Insurance Portability and Accountability Act (HIPAA). Under HIPAA employers are banned from discriminating on the basis of employee health status under their group insurance plan, if one is offered. The discrimination would be charging some employees higher premiums or excluding them from some health benefits that other similarly situated employees receive. But the ACA permits and encourages workplace wellness plans, both a participatory kind (in which some health-promoting opportunity is provided) and so-called health-contingent wellness programs (in which employees must meet a specified health standard to earn a reward, such as achieving weight or blood pressure goals to receive a premium reduction). Just offering wellness incentives to participate in some program or activity like attending an exercise class does not trigger much suspicion under the new regulations because no punitive outcome is attached to failure to lose weight, for example. Health-contingent programs, by contrast, sort employees and charge them different rates for health coverage based on their achievement of certain health goals. Under proposed rules set to go into effect in 2014, employers could offer rewards worth up to 30 percent of the cost of coverage for achieving a health benchmark and up to 50 percent if the goal is



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smoking cessation or reduction (Incentives for Nondiscriminatory Wellness Programs in Group Health Plans; Proposed Rule, 77 Fed. Reg. 70,619 (2012)). The proposed regulations and government websites consistently (and mysteriously) refer to wellness programs as ‘‘nondiscriminatory wellness programs,’’ but the entire purpose behind the law is to create an exception permitting health-based discrimination where it was previously illegal. This new legal permissiveness for differential treatment on the basis of health is my starting point in this special issue. In this article I trace out the theoretical roots of wellness ideology and set out the basic terms of pushback against them. The Well Person Is the Always Striving Person

The most important ideological construction of corporate wellness is its emphasis on maximizing the functioning of the individual. The striving, becoming, improving person has been at the center of wellness discourse for many decades and has seamlessly become the ideal employee. Why companies would want this person held up as the ideal worker is obvious, but we should be careful not to let this wellness norm dictate hierarchies of citizens in our democratic community. As Halbert L. Dunn (1961: 4–5) put it in his foundational treatise on ‘‘high-level wellness,’’ wellness is ‘‘an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable . . . requir[ing] that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning.’’ Dunn (1961: 5) acknowledges that of course we all have limitations, but we should nonetheless resist stasis and always strive for ‘‘maximizing,’’ ‘‘becoming,’’ reaching our potential with ‘‘the very best that we can do, within those limitations.’’ That is, the individual should be continually striving for self-improvement and better functioning. He should not be idle, depressed, bored, uncooperative, unskilled, tired, swamped, stressed, or content with his middling level of fitness. This striving person fits perfectly into the ideology of functional personhood so prominent in our antidiscrimination laws, where the dictum is to ignore the person’s outwardly appearing traits such as race or sex and simply attend to whether she can do the job (Post 2001). To do justice to someone is to care only about her level of functioning in the capitalist workplace, on this account. This account of justice to persons is often hard to square with medical care because physicians consider outwardly appearing traits such as race, sex, and especially body weight to be relevant to their assessments, not distracting and irrelevant (Kirkland 2009). But the



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wellness regime brings these together again in the workplace with its promise to strip down to the most revealing health information and to maximize what everyone agrees should be the focus: employee functioning. This new union of wellness and functional personhood, however, threatens to let discriminatory animus creep back in the back door disguised as health factors rather than protected traits. One of the odd things about workplace wellness programs is that they often allow employees to take time out of the workday to engage in wellness activities, seemingly in tension with productivity goals. But this permission is better understood as supporting, not diluting, the pressure to be always striving, always working, always focused on the self and its betterment. For the organization to let an employee take an hour to work out during the day in exchange for buy-in to this concept of continual selfbetterment is more than worth it. In a culture in which both health and work are about striving, self-discipline, and individual achievement, corporate interests are perfectly aligned with health discourses. If we were to attribute poor health outcomes to structural inequalities that require systemic fixes through democratic engagement, however, corporate interests and individual striving would become marginal to any solutions. Nothing is wrong with striving for self-improvement per se. But it cannot be the answer to the problem of health care costs and health inequalities in a society that is much more than groups of corporate employees. Three Critiques of Wellness

Criticisms of wellness now come in several varieties: (1) the economic and result oriented, in which critics argue that wellness programs do not actually have the health and cost-saving benefits claimed; (2) the normative or more theoretical, in which critics describe wellness as an ideology that suppresses human variation and creates hierarchies based on the achievement (or the appearance of achievement) of health goals and lifestyle practices of the elites in contemporary Western societies; and (3) the sociological, in which wellness culture as practiced in organizations is argued to be a form of social control that may not be entirely desirable, at least not for everyone. The economic and result-oriented critiques tend to stand apart from the normative and the sociological, while the normative and sociological critiques often blend together. That is, aspects of workplace wellness programs may well be worth criticizing even if they reduce health care costs. If they do not really work to reduce costs and still have negative ideological or cultural impacts, the



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critique is even stronger. One fascinating fact about corporations that implement wellness programs today is that 75 percent of the midsize companies and nearly 80 percent of the large companies do not even include a plan to evaluate their return on investment (ROI) (ADP Research Institute 2012: 6). If, indeed, investments in wellness programs do not pay off for companies (perhaps because they reward only the already healthy or because any health benefit accrues after the employee has left the firm) and, furthermore, the large majority of companies do not even care about finding out whether wellness programs pay for themselves, then having a wellness program must be serving other important interests. Perhaps investment in wellness has become a critical part of corporate citizenship and employee satisfaction. Perhaps a certain picture of health and vigor has come to stand in for the desirable employee, and wellness programs are a clear way to signal that achievement and to sort employees. Perhaps fear about rising health care costs and the conviction that wellness programs must work are both so strong that they are simply beyond question. Perhaps a few decades of wellness programming has generated a class of ‘‘wellness entrepreneurs’’ selling, managing, implementing, and supporting them so that they are as much a part of corporate culture as diversity training is. Perhaps withdrawing a wellness program after evaluating its poor ROI is unthinkably defeatist, and therefore firms would prefer to run symbolic programs that do not cost very much in the first place. While this article focuses on the normative and sociological critiques of wellness rather than on the economic, result-oriented critiques, I take their implication to be that the normative and sociological force behind wellness initiatives is strong indeed. It may be so strong that wellness is worth having (from the perspective of those implementing the policy, of course) regardless of its economic payoffs. What, then, does wellness do that is so important? How is wellness put to use today? In the next section, I consider three versions of the normative and sociological criticisms of wellness and consider examples, counterexamples, and implications. The criticisms are (1) that wellness programs create and perpetuate undesirable hierarchies, (2) that wellness programs as actually implemented in firms will promote discrimination, and (3) that wellness ideology promotes a single-minded and detailed view of what kind of life is worth living and does not deserve dominance in a highly diverse democratic society such as ours. Wellness creates hierarchies based on the achievement (or the appearance of achievement) of health goals and lifestyle practices of elites in contemporary Western societies. This critique of wellness begins from the observation that the work of wellness is steeped in the language of personal



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responsibility and the duty of the individual to take up preventative personal strategies to maximize her health to reduce costs for the corporation or for government benefit programs. If this duty is problematic, it must be because (1) achieving better health is not entirely or even mostly in the individual’s personal control, and so placing responsibility there will only reward the luckier and more advantaged and punish the unlucky and those with fewer resources; (2) even if personal health is somewhat or significantly determined by individual actions and omissions, spheres of control are nonetheless unjustly distributed to begin with, and so setting rewards and punishments at those same levels will also only cement and naturalize unjust hierarchies; (3) the shaming techniques that will have to be part of the public health program of wellness as well as the corporate practices of wellness are unjust because they do not improve health or because they damage personal dignity too much to be morally acceptable, or both; (4) the increased focus in law, business, and culture on personal wellness overwhelms the political conversations about health and health care provisioning so that designing structural or redistributive solutions is no longer feasible because the notion that individual behavioral changes can fix everything will be so hegemonic; or (5) some combination of these. Wellness promotes a conservative, individualistic health ideology, thereby undercutting communal, structural, redistributive, and sympathetic approaches to health. The more health is framed as within personal control, the more it will seem that everyone deserves his or her place in the health hierarchy. Wellness is thus poised to help push American health politics farther to the right. This argument may seem surprising, since many of the practices of wellness are associated with left-leaning, elite lifestyles in the contemporary United States, or it simply may not seem very political at all. Examining the ideological underpinnings of wellness and comparing them to what social scientists know about the political pull of various ideological commitments will warn against assuming that wellness efforts are necessarily progressive or liberal. Research in political psychology suggests that economically conservative ideologies are highly associated with social dominance, or an affinity for seeing the world as a competitive, dog-eat-dog place (Jost, Federico, and Napier 2009). Liberals are much more comfortable with social change, uncertainty, and equality than conservatives are (ibid.). The American public is much more likely to blame individuals for their weight, while public health professionals, policy elites, and political liberals generally agree that environmental and genetic causes are better culprits to pursue (Oliver and Lee 2005). A problem arises if one embraces wellness programs out of a belief that they will uplift



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unhealthy people, promote social change, and ease health disparities between groups. Less potential conflict occurs if one embraces wellness programs out of a belief that they will allow the motivated to become more vigorous and that whatever benefits come about are justly deserved only by those who really tried. A wellness regime that justifies status quo health and economic hierarchies by rewarding the already healthy and the well employed creates a dilemma therefore only for the left side of the political spectrum. The dilemma is how to encourage those who could benefit to adopt wellness behaviors without either failure through benign neglect (because wellness programs do not really benefit poor people anyway) or failure through stigmatization and entrenchment of inequality (because wellness ideology conceals—even from well-meaning liberals themselves—the fact that it actually blames the unhealthy for their conditions and justifies their reduced status). Striving for wellness is a personal responsibility that an individual can achieve if she really wants to, and if she fails to undertake it, it must be because she lacks information, access, or incentive. Explanations for both success and failure rest primarily with the individual once the company or community provides some access, no matter how symbolic, inaccessible, or inconvenient. The combination of individual focus with merely symbolic provision of resources keeps failure individualized and provides cover for punitive measures if the employee cannot transform herself. Individualistic definitions help maintain hierarchies because slim, healthy, relaxed, and vigorous individuals are already high status (both because these qualities are the result of being high status and because having them or being born with them also increases status) (Campos 2004; Guthman 2011; Kirkland 2011; Saguy 2013). On the other end, the failure to provide affirmative goods, institutions, and structures beyond what the individual can already do for herself often means that those who are excluded from attainment will remain so. Wellness is not generally associated with environmental cleanup efforts, more frequent and accessible public transit, food safety inspections, or the provision of safe jobs paying decent wages, for example (all more structural, government-provided, health-linked improvements that would benefit the poor). Wellness programs as actually implemented within firms and organizations will promote workplace discrimination. Many of the contributors to this special issue touch on discrimination as a possible problematic feature of wellness programs. My particular aim here is to describe how the foundational theoretical commitments of wellness ideology may create climates that promote inequality and discrimination. Whether these climates exist or materialize and whether they have the precise effects I



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hypothesize are very local matters that are difficult to predict without examining a particular business culture and program implementation. If my arguments are compelling, they are so because I illuminate aspects of wellness ideology and culture that we already understand as capable of creating discriminatory climates. Workplace wellness programs are designed to improve the health of an existing workforce. Under HIPAA employers are not allowed to exclude some employees from their group health plans or to charge them more based on their health status, so firms cannot explicitly sort through employees and discard the expensive ones. But of course another obvious way to improve the overall health profile of one’s workforce and reduce costs is to avoid hiring or to fire or ease out employees who may have higher health care costs. An internal Wal-Mart Stores memorandum (leaked and published in its entirety online by the New York Times in 2005) discussing strategies for health care cost reduction is helpfully explicit. Because it is ‘‘far easier to attract and retain a healthier workforce than . . . to change behavior in an existing one,’’ Wal-Mart executives suggested ways to ‘‘dissuade unhealthy people from coming to work at Wal-Mart’’ (Chambers, n.d.: 14). The memorandum suggested three ways to attract healthier workers: (1) ‘‘design all jobs to include some physical activity (e.g., all cashiers do some cart-gathering),’’ (2) offer savings on fruits and vegetables, and (3) offer benefits ‘‘that appeal to healthy Associates (e.g., an education offering targeted at students)’’ (ibid.). The Wal-Mart proposal was not meant to be a wellness program precisely, but I am suggesting that it is an example of a corporate wellness strategy taken just one logical step further: not only make your current employees healthier (or what Scott L. Greer and Robert D. Fannion [2014] call ‘‘positive wellness’’ in their article in this issue), but keep less healthy workers out for the future (or what Greer and Fannion call ‘‘negative wellness’’). The second and third prongs are carrots. The stick of the physical activity requirement attracted much more controversy. It is clearly problematic under disability rights and pregnancy discrimination laws because it sends the message that only people who can be vigorous in standard ways are welcome to work in any type of job at the company. The proposed physical activity requirement could work by sending the message that it would be better to be a cashier elsewhere to people with mobility impairments or asthma, older people, fat people,1 very small or weak people, pregnant 1. I consciously adopt the term fat following fat rights activists’ attempts to render the word a straightforward descriptor like tall or brown-haired. I use obesity or overweight when it is necessary to mirror the health community’s use of those terms, though fat rights activists find these terms offensive.



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women or women imagining that they might become pregnant while on the payroll, and anyone for whom gathering carts outside in all weather would be unappealing. The rule, if implemented, would give a company a handy way to reconfigure its employee pool to make it healthier and cheaper. Any refusal to perform the physical activity would be insubordination and grounds for dismissal. It could also function legally as an ‘‘essential function’’ of the job, and under the Americans with Disabilities Act (ADA), any employee would have to show that she could still perform these functions with or without an accommodation. The Pregnancy Discrimination Act (PDA) requires employers to treat pregnant women the same way they treat anyone else, not better or with any accommodations, and so if the physical activity job requirement applied to everyone equally, there would be no defense for a pregnant woman protesting against pushing carts. How this cart gathering would work in practice is interesting to imagine. Nearly every person I have ever observed out gathering carts has been male. Could such a requirement realign the gendered assignments of jobs, putting men at the cash registers and women in the parking lot and the loading docks? Like any intervention into social life, we cannot know beforehand exactly what the practices will mean and how they will rearrange roles. Perhaps such a rule would keep less robust people from applying or being hired (perhaps with a greater impact on women, who may be more likely to be or to perceive themselves to be in that category) but would actually enact more gender equality on the floor among the hired employees. But this degendering would come at the expense of more age, disability, weight, and health discrimination. The Wal-Mart cart-gathering proposal is an explicit real-world reminder that wellness programs will function within organizations actively looking for ways to lower their health insurance costs, and it is only reasonable to assume that wellness will be subsumed in these calculations. When wellness programs push or even require physical activity, they are sorting employees and would-be employees on that basis and creating hierarchies based on ability, aptitude, and willingness to be physically active in the prescribed way. A discount on fruits and vegetables was the very next WalMart proposal, but its proximity to an explicit plan to weed out the weak should remind us that assistance in good health habits can be closely bound up with punitive exclusions. Whether and to what extent this kind of health discrimination (or, more accurately, ‘‘guess-about-future-costs discrimination’’) is legal is a fairly complex question that is discussed in detail throughout this special issue (see in particular Madison, Schmidt, and Volpp 2014). Many kinds of persons might attract such discrimination, and



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such discrimination might take many forms. The essential point is that health is already tightly linked to race and class hierarchies in contemporary US society, and employees come to the wellness program already sorted along these lines. The question is whether wellness programs will enhance health for everyone or only deepen preexisting divisions. Wellness is constituted in a nest of intersectional identity categories that will help enact what it means in practice. For example, wellness careers, wellness ideals, wellness images, wellness programs, and wellness ideologies can all be gendered or racialized in the same way any social formation can be. Women, for example, often do the work of wellness. At the Thirty-First Annual Wellness in the Workplace Conference I attended in March 2012, in Ann Arbor, Michigan, the job of wellness consultant was overwhelmingly filled by slender or at least not-fat white women in their thirties and forties. I counted about 250 people in the room at the event, and I could count on one hand the number of nonwhite faces. Women are also the clients of wellness. Women are overwhelmingly the consumers of wellness products such as alternative remedies, yoga and fitness classes, diet plans, and weight-loss groups. The hallmarks of achieved wellness — slenderness, flexibility, relaxation, control, a delicate appetite — are the visage of elite female beauty in our society. This picture of femininity generally describes a white woman, although Asian women may be favored in wellness culture for their generally smaller body type and for the orientalist sense that they embody non-Western harmonious living. Motherhood, too, has a wellness prescription. The popular Wellness Workbook (which explicitly adopts Dunn’s language of high-level wellness) asks readers to reconsider their values in opposition to the dominant culture, and ‘‘mothers returning to work and leaving their very young child(ren) in the care of random strangers’’ appears on the same list of regrettable norms as driving short distances, taking the elevator instead of the stairs, smoking, bottle-feeding, drinking coffee, and not seeing oneself as being as capable as one could be (Travis and Ryan 2004: xxiv). These are strongly moralistic norms, and the prohibitions on coffee, day care, and bottles are on much shakier evidentiary ground than the urgent tone suggests. In the workplace context, working mothers are likely to be particularly pinched by the pressure not only to find time for workouts and healthy eating for themselves but also to be the picture of wellness success that includes intensive health-focused mothering outside the workplace. When children’s exercise opportunities rely on middle-class mothers’ leisure time spent ferrying them from activity to activity, it is easy to see how healthy mothering and wellness for mothers might be



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quite different things. For lower income and single mothers, meeting the demands of successful child rearing and wellness enhancement may be even more impossible. Allowing oneself to feel overwhelmed by all these expectations is yet another failure—the failure to strive, to maximize, to see oneself as highly capable of overcoming obstacles in the pursuit of wellness. Weight loss is the most obvious goal of many workplace wellness programs (perhaps second only to smoking cessation), and weight loss is much more important for women than for men. That is, perceived excess weight is much more deleterious to women’s careers than to men’s (for educated white women in particular), and similar amounts of excess weight attract more discrimination to a woman’s body than to a man’s (Rhode 2010; Saguy 2012). Evidence of discrimination begins to appear at much smaller weights for women than for men, for whom a wide range of body types appears to be acceptable. Black women are the fattest subgroup in the contemporary US population, and therefore the likelihood that a black woman in an organizational setting will stand out for her weight is fairly high (though, interestingly, data suggest that she will not be as penalized for it on her paycheck as her white counterpart would be, perhaps because her body is not ideal to begin with) (Brownell et al. 2005). If my observations about the demographics in the wellness profession are generalizable, this hypothetical black woman will not be in charge of the wellness program. Program materials, messages, offerings, and target benchmarks are unlikely to be developed with people of color present, especially poor and fat ones. Not only will white people run wellness programs and inflect them with the norms for eating and healthy living from elite white culture, but psychological research tells us that they may be likely to associate deviance from the wellness program—laziness, consumption of low-status food, fatness, and happiness with fatness—with minority status (Saguy and Gruys 2010). These biases will make minority employees stand out when their behaviors or body types align with these low expectations. In concrete terms, everyone will be more likely to notice the black or Latina employee holding a soda or eating a doughnut and will be much more likely to attribute that event to a general pattern of dissolute living and to consider the person a burden on the group. If many of the ways that one can work as a wellness administrator or fail at wellness are inflected with femininity, then we may not be surprised that the more active, positive, and forceful pronouncements of wellness cohere well with ideas about masculinity. Many of the leading definers of wellness since the inception of the term have been men, and the emphasis in wellness



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discourse on continual striving and self-discipline aligns well with conceptions of the high-achieving male. Wellness discourses stress individual performance and willpower and thus prop up the image in our society of the ideal worker: a man who does not have other distractions outside work—child or elder care, for example—that take him away from the job. In my survey of wellness promotion literature and at the workplace wellness conference mentioned above, disability either never even appears or else is figured exclusively as the poor health that comes from bad choices. When disability is considered at all, it is understood as something to be brought into the wellness program with specific accommodations for disabled employees so that they may pursue wellness too. Wellness is supposed to be a process that everyone in any condition can begin, but this universal openness combines with an actually quite narrow regimen of activities and acceptable outcomes. As Carrie Griffin Basas (2014) elaborates in her contribution to this special issue, wellness programs often pose problems on many levels for people with disabilities. Discrimination may simply appear as exclusion, such as inaccessible fitness classes. Fixing accessibility issues can be relatively straightforward, however (such as holding classes in an accessible location and adding exercises that can be done from a wheelchair). We can expect that if an organization recognizes accessibility as a problem, it could without too much difficulty accommodate disabled employees in the wellness regime already operating (especially if those employees have already managed to secure jobs there in the first place). Current law requires that any wellness program that includes incentives must have an alternative way to fulfill the requirements if they are unreasonable for a person’s condition (Mello and Rosenthal 2008). The tougher question is whether and in what ways the overall tone of wellness rhetoric is fundamentally inhospitable to a disability rights ethic. Wellness promoters use the language of ‘‘defect’’ and ‘‘defective,’’ seemingly quite unaware of how these terms sound to someone acquainted with the history of eugenics in the United States and Europe (Mitchell and Snyder 2003). At the workplace wellness conference I attended, a former employer-side employment attorney who now leads human resources in an international metal manufacturing company compared wellness programs to efforts to increase workplace safety and decrease defects in products. We already act to prevent injuries and workers’ compensation claims and prevent defects, he reasoned, and so wellness programs act on employees to prevent medical defects and health defects in the workplace. Overwhelmingly, the targeted defects are smoking, excess weight, high blood



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pressure, and inactivity. Or, put another way, smokers, fat and plump people, and sedentary people are the defects. From a disability rights perspective, any program aimed at eliminating problematic bodies and making them acceptable will inevitably carry on the message that people are rightly arranged in a hierarchy from successful, healthy, and normal to pitiful, contemptible, and defective. In other words, the world would be a better place if wellness programs could help eliminate certain kinds of people from the population (by remaking them into different and better people). Companies are not responsible for the population, of course, so they would simply try to remove those types of people from their employment rolls by changing them, firing them, or not hiring them. We might embrace the elimination of racists, sexists, and homophobes by their transformation into nonracist, nonsexist, and nonhomophobic people, of course, so changing people and hierarchically valuing some traits over others is not necessarily a bad thing. Current disability rights laws have done very little to get disabled people into jobs, and people with disabilities are among the poorest in our society, however (Bagenstos 2004). Violations of accessibility laws are widespread, and there is little enforcement beyond litigation, which is uncertain, burdensome, and often ineffectual (Burke 1997). If the world of organizations becomes even more hostile to variations in health and bodies because wellness programs end up further cementing and justifying these inequalities, we will feel the impact throughout our society as more people are more effectively screened out of employment opportunities. Hearing that the wellness program now welcomes wheelchair workouts will not allay these concerns. Wellness promotes homogeneity and prescribes one specific way of life for everyone and is thus a problematic trend in a highly diverse democratic society. Given all the things one could strive for, should wellness be the favored choice of the state and the workplace? What about striving for enlightenment or religious piety, turning away from focus on the self to service to others, or simply not striving at all and living in contented stasis with one’s habits and body? How much force shall we put behind one version of this choice of how and whether to exert ourselves? This version of the objection recognizes that while wellness promotes neoliberal individualism, it is importantly different from the sentimental individualism of American life. That sentimental individualism imagines people pursuing highly variable life plans in the context of deep disagreement about what the best path is. Whether a life of smoking, drinking, and writing novels is worth less than a life of steamed vegetables, exercise, and assiduous striving for wellness is simply not for someone else to say. The neoliberal



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individualism of wellness, by contrast, is focused on moving caretaking from the communal health system to the individual, and thus it is individual as a placement of responsibility rather than as a site of innovation or rights. It is anti-individual in its univocal endorsement of a quite homogeneous set of life choices, activities, attitudes, and even habitus (to borrow Pierre Bourdieu’s [1984] term meant to capture the class membership signals that a person sends with his or her clothes and grooming, consumption choices, voice inflections, and word choices, for example). One should not look unkempt, pant too much on the stairs, eat quickly and heedlessly, or project indifference to striving for self-optimization. None of these norms are officially part of any wellness program, of course, but I am arguing that elite agreement on what wellness looks like is enough to be able to sort people based on their levels of achieving it. On this account, we know exactly what everyone should be doing to achieve wellness, and the problem is just getting everyone to do it. I term this epistemic healthism, or knowing for sure what must be done to achieve wellness. If only everyone could be made aware and then see the obvious correctness of the wellness-focused life, we would all begin to do a lot of the same things. The program narrowed down to its essential elements is (1) no smoking; (2) exercise; (3) a moderate diet conforming to what cultural elites would define as healthy in our culture at the moment, perhaps most succinctly captured in Michael Pollan’s (2008: 1) dictum ‘‘Eat food, mostly plants, and not too much’’; and (4) achievement of the health numbers—body mass index (BMI), cholesterol, blood pressure, blood glucose—that are thought to be the outcomes of such a regime. Tobacco products should not even exist in such a world, nor should all the low-status convenience foods (Pollan’s ‘‘edible foodlike substances’’ [ibid.]). The world would be a better place without all these products—if no one wanted them, if the companies that make them all went out of business, if no one’s life included them. A world without tobacco may be the easiest case to agree on, though history, culture, pleasure, and autonomy would no doubt complicate that conclusion as well (Klein 1993). And without the products and life patterns singled out for criticism in The Wellness Workbook—alcoholic beverages, baby formula, day care centers, coffee, elevators—the world would also be an obviously better one. Importantly, these things would not be forcibly taken away in the name of wellness. We currently live in a world in which people persist in wanting many of these supposedly unhealthy pleasures and conveniences, and the discussion among wellness devotees is about how much regulation is possible under antagonistic conditions (consumer demand for bad food and cigarettes). I



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am suggesting that we should imagine getting what wellness advocates want: a world in which everyone agrees that the pursuit of wellness should be at the center of one’s life plan and everyday habits. What would everyone agree about, and what would such a world be like? Wellness advocates would say that such a world would simply be one in which everyone continues to pursue his or her life plan but in a healthier, more vigorous way that avoids disability, disease, and a prolonged decline and miserable or too-early death. We could still have our Hemingways but without the smoking and the drinking, that is (just as the illustrator Clement Hurd’s cigarette was airbrushed out of his hand in the jacket photo on the beloved children’s book Goodnight Moon [Wyatt 2005]). Perhaps these habits that would no longer exist currently contribute little to people’s personal styles, capacities for transgression or innovation, pleasure, or coping abilities. Perhaps we could excise these habits and redirect people’s energies toward wellness pursuits without altering the social world so much that we lose more through the coercion than we gain in saved health care costs. Perhaps we would remain empathetic toward those who get cancer or become disabled by chronic disease anyway and still find a dignified place for them in our society. But if we find this imagined world vaguely dystopic, we should check our enthusiasm for its preconditions. Conclusion: Predictions about Wellness in Legal-Organizational Culture

Wellness advocates would say that corporations are well within their rights to choose vigorous employees and to try to lower their health care costs (at least within the restrictions of civil rights laws) and that we have no reason to panic that workplace wellness is going to take over democratic citizenship. Imagined worlds like the one outlined above are just silly overstatements, in this view. These advocates would also say that firms will manage their wellness programs within guidelines set out by HIPAA, the ACA, and applicable civil rights laws and that if they discriminate, they will rightly be sued. The occasional act of discrimination by a bad actor cannot really be prevented, and on this view workplace wellness does not set up any institutionalized discrimination. It is worth reflecting, however, in closing, on what we know about how the legal and organizational fields interact, before we assume that exogenous legal rules against discrimination will stand over firms and prevent slippage into discriminatory practices. Sociologists of law already well understand that businesses embrace symbolic expressions of compliance with antidiscrimination laws and that judges interpret these sympathetically



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(Edelman 1992, 2005). Business practice becomes incorporated into legal precedent about what is reasonable to do to prevent discrimination, and when a business does the standard thing, such as publish a statement that it does not discriminate or hold a workshop, judges defer to the business and accept that it did not discriminate (Edelman et al. 2011). Scholars have also documented the tendency of rights-based legal language to become ‘‘managerialized,’’ or remade into terms more hospitable to the work environment during its take-up and use in the daily life of organizations (Edelman, Fuller, and Mara-Drita 2001). For example, diversity came to mean a helpful array of different perspectives (a business-friendly rationale untethered from any violations of rights) rather than affirmative action for racial minorities and women (a civil rights remedy for past group-based wrongs). Wellness comes already packaged in individualistic, businessfriendly terms. The requirement that a business give notice of the alternative way of earning a reward to those who cannot achieve the benchmark (say, attaining a certain BMI to obtain a lower insurance payment) will be easy to comply with in a superficial way, making it very difficult for employees to argue that the alternative was unfair, not really well advertised, or too inconvenient. Wellness programs have been around for decades, and they have just been more firmly rooted in American law, culture, and work through their expansion under the ACA. What they will mean, how much influence they will have, and how and whether they will transform health and life opportunities (and in what direction) is not yet clear. Studying what wellness becomes will continue to be of pressing importance for scholars in many disciplines who work at the intersections of work, health, politics, power, and identity.

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Anna Kirkland is associate professor of women’s studies and political science at the University of Michigan. She holds a JD and a PhD from the University of California, Berkeley (Jurisprudence and Social Policy Program). Kirkland is the author of Fat Rights: Dilemmas of Difference and Personhood (2008) and coeditor with Jonathan Metzl of Against Health: How Health Became the New Morality (2010). Her current book project explores how activists and government actors come to know and understand vaccine injuries and what recent debates over vaccine safety reveal about democratic engagement with volatile scientific questions in the contemporary United States. Recent publications include ‘‘Credibility Battles in the Autism Litigation’’ (2012), ‘‘The Legitimacy of Vaccine Critics: What’s Left after Autism?’’ (2012), and ‘‘The Environmental Account of Obesity: A Case for Feminist Skepticism’’ (2011).



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References ADP Research Institute. 2012. ‘‘Employers See Wellness Programs as Key to Containing Rising Healthcare Costs.’’ ADP Advisor 22, no. 2: 1–7. Bagenstos, Samuel R. 2004. ‘‘The Future of Disability Law.’’ Yale Law Journal 114, no. 1: 1–83. Basas, Carrie Griffin. 2014. ‘‘What’s Bad about Wellness? What the Disability Rights Perspective Offers about the Limitations of Wellness.’’ Journal of Health Politics, Policy and Law 39, no. 5: 1035–66. Bourdieu, Pierre. 1984. Distinction: A Social Critique of the Judgement of Taste. Translated by Richard Nice. Cambridge, MA: Harvard University Press. Brownell, Kelly D., Rebecca M. Puhl, Marlene B. Schwartz, and Leslie Rudd, eds. 2005. Weight Bias: Nature, Consequences, and Remedies. New York: Guilford. Burke, Thomas. 1997. ‘‘On the Rights Track: The Americans with Disabilities Act.’’ In Comparative Disadvantages? Social Regulations and the Global Economy, edited by Pietro Nivola, 242–318. Washington, DC: Brookings Institution. Campos, Paul F. 2004. The Obesity Myth: Why America’s Obsession with Weight Is Hazardous to Your Health. New York: Gotham Books. Chambers, Susan. n.d. ‘‘Reviewing and Revising Wal-Mart’s Benefits Strategy: Memorandum to the Board of Directors from Susan Chambers.’’ Confidential memo prepared for Wal-Mart Board of Directors Retreat FY06. www.nytimes.com /packages/pdf/business/26walmart.pdf (accessed April 29, 2013). Conrad, Peter. 1987. ‘‘Wellness in the Work Place: Potentials and Pitfalls of Work-Site Health Promotion.’’ Milbank Quarterly 65, no. 2: 255–75. Conrad, Peter. 1988. ‘‘Worksite Health Promotion: The Social Context.’’ Social Science and Medicine 26, no. 5: 485–89. Conrad, Peter. 1994. ‘‘Wellness as Virtue: Morality and the Pursuit of Health.’’ Culture, Medicine, and Psychiatry 18, no. 3: 385–401. Dunn, Halbert L. 1961. High-Level Wellness: A Collection of Twenty-Nine Short Talks on Different Aspects of the Theme ‘‘High-Level Wellness for Man and Society.’’ Arlington, VA: R. W. Beatty. Edelman, Lauren B. 1992. ‘‘Legal Ambiguity and Symbolic Structures: Organizational Mediation of Civil Rights Law.’’ American Journal of Sociology 97, no. 6: 1531–76. Edelman, Lauren B. 2005. ‘‘The Endogeneity of Law: Civil Rights at Work.’’ In Handbook on Employment Discrimination Research: Rights and Realities, edited by Robert L. Nelson and Laura Beth Nielsen, 337–52. New York: Kluwer Academic. Edelman, Lauren B., Sally Riggs Fuller, and Iona Mara-Drita. 2001. ‘‘Diversity Rhetoric and the Managerialization of Law.’’ American Journal of Sociology 106, no. 6: 1589–1641. Edelman, Lauren B., Linda H. Krieger, Scott R. Eliason, Catherine R. Albiston, and Virginia Mellema. 2011. ‘‘When Organizations Rule: Judicial Deference to Institutionalized Employment Structures.’’ American Journal of Sociology 117, no. 3: 888–954.



988


EOHHS (Executive Office of Health and Human Services). 2014. ‘‘Mass in Motion Municipal Wellness and Leadership Program.’’ Boston: EOHHS. www.mass.gov /eohhs/gov/departments/dph/programs/community-health/mass-in-motion/community /municipal-program. Greer, Scott L., and Robert D. Fannion. 2014. ‘‘I’ll Be Gone, You’ll Be Gone: Why American Employers Underinvest in Health.’’ Journal of Health Politics, Policy and Law 39, no. 5: 989–1012. Guthman, Julie. 2011. Weighing In: Obesity, Food Justice, and the Limits of Capitalism. Berkeley: University of California Press. Jost, John T., Christopher M. Federico, and Jaime L. Napier. 2009. ‘‘Political Ideology: Its Structure, Functions, and Elective Affinities.’’ Annual Review of Psychology 60, no. 1: 307–37. Kirkland, Anna. 2009. ‘‘Revisiting Rights across Contexts: Fat, Health, and Antidiscrimination Law.’’ Studies in Law, Politics, and Society 48: 121–45. Kirkland, Anna. 2011. ‘‘The Environmental Account of Obesity: A Case for Feminist Skepticism.’’ Signs: Journal of Women in Culture and Society 36, no. 2: 463–85. Klein, Richard. 1993. Cigarettes Are Sublime. Durham, NC: Duke University Press. Leichter, Howard M. 1997. ‘‘Lifestyle Correctness and the New Secular Morality.’’ In Morality and Health, edited by Allan M. Brandt and Paul Rozin, 359–78. New York: Routledge. Madison, Kristin, Harald Schmidt, and Kevin G. Volpp. 2014. ‘‘Using Reporting Requirements to Improve Employer Wellness Incentives and Their Regulation.’’ Journal of Health Politics, Policy and Law 39, no. 5: 1013–34. Mello, Michelle M., and Meredith B. Rosenthal. 2008. ‘‘Wellness Programs and Lifestyle Discrimination—the Legal Limits.’’ New England Journal of Medicine 359, no. 2: 192–99. Mitchell, David, and Sharon Snyder. 2003. ‘‘The Eugenic Atlantic: Race, Disability, and the Making of an International Eugenic Science, 1800–1945.’’ Disability and Society 18, no. 7: 843–64. Oliver, J. Eric, and Taeku Lee. 2005. ‘‘Public Opinion and the Politics of Obesity in America.’’ Journal of Health Politics, Policy and Law 30, no. 5: 923–54. Pollan, Michael. 2008. In Defense of Food: An Eater’s Manifesto. New York: Penguin. Post, Robert C. 2001. Prejudicial Appearances: The Logic of American Antidiscrimination Law. With K. Anthony Appiah, Judith Butler, Thomas C. Grey, and Reva B. Siegel. Durham, NC: Duke University Press. Rhode, Deborah L. 2010. The Beauty Bias: The Injustice of Appearance in Life and Law. New York: Oxford University Press. Saguy, Abigail. 2012. ‘‘Why Fat Is a Feminist Issue.’’ Sex Roles 66, nos. 9–10: 600–607. Saguy, Abigail. 2013. What’s Wrong with Fat? New York: Oxford University Press. Saguy, Abigail, and Kjerstin Gruys. 2010. ‘‘Morality and Health: News Media Constructions of Overweight and Eating Disorders.’’ Social Problems 57, no. 2: 231–50. Travis, John W., and Regina Sara Ryan. 2004. Wellness Workbook: How to Achieve Enduring Health and Vitality. Berkeley, CA: Celestial Arts. Wyatt, Edward. 2005. ‘‘‘Goodnight Moon,’ Smokeless Version.’’ New York Times, November 17.


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