When Systemic Fatphobia Works “For” You
Warning: This post contains discussion of medical fatphobia, including use of the term “obese.”
On Wednesday, before receiving my second dose of the Pfizer COVID-19 vaccine, I had to answer a few questions. The last one was seemingly simple, but also packed with meaning: “What qualifies you for the vaccine?”
I said, “Underlying health issues,” and it felt like a lie. I’m chronically ill, but I am not immunocompromised. I do not have asthma. I am not in a high-risk age group. I don’t work on the front lines. I qualify because my BMI — Body Mass Index — is 43.8, classifying me as “super morbidly obese.”
BMI is basically junk science, but doctors still use it as an overall indicator of health, because they assume — despite overwhelming evidence to the contrary — that body size always directly correlates to a person’s health. It doesn’t, but even if it did, that shouldn’t preclude people from human decency. In general, fat people don’t get a lot of that from anyone — most especially medical professionals. Fat people avoid going to the doctor because we are usually ignored, antagonized, and/or prescribed what many doctors believe is a cure-all: Weight loss.
For lots of fat people, myself included, there’s trauma wrapped up in seeking medical attention for any reason, even (and especially) if it has nothing to do with weight. Doctors will find almost any excuse to suggest weight loss, which is partially because most insurance companies won’t pay if “obese” patients aren’t lectured about their weight during an appointment. Broken toe? Lose weight. Hearing loss? Lose weight. Can’t breathe? Lose weight.
The last one is particularly relevant to the topic at hand. When the COVID-19 pandemic began and hospital beds became scarce, rumors began to spread that fat patients were being denied ventilators because doctors didn’t think they deserved them. Ultimately, this is the issue at hand: Whether or not body size correlates with risk for COVID-19, fat patients are less likely to get the care they need to survive. A recent study conducted by the CDC, involving over 150 thousand adults at more than 200 hospitals in the U.S., claims fat patients — specifically, patients with a BMI of 30+ — are more likely to be hospitalized or even die from the virus.
However, reporting in The New York Times denotes how little researchers actually know about this supposed correlation. From the article, written by Emily Anthes and published March 8:
Patients with a B.M.I. of 45 or higher, which corresponds to severe obesity, were 33 percent more likely to be hospitalized and 61 percent more likely to die than those who were at a healthy weight, the researchers found.
“The findings of the study highlight the serious clinical public health implications of elevated B.M.I., and they suggest the continued need for intensive management of Covid-19 illness, especially among patients affected by severe obesity,” said the lead author, Lyudmyla Kompaniyets, a health economist at the Division of Nutrition, Physical Activity and Obesity at the C.D.C.
…
Patients with a B.M.I. of 30 to 34.9 were just 7 percent more likely to be hospitalized and 8 percent more likely to die than people who were at a healthy weight, but the risks increased sharply as B.M.I. rose.
…
Dr. Kompaniyets and her colleagues also documented a linear relationship between B.M.I. and the likelihood of needing mechanical ventilation; the higher the B.M.I., the more likely a patient was to require such intervention, which is invasive and can come with serious complications.
The study also found that patients who were underweight, with a B.M.I. below 18.5, were 20 percent more likely to be hospitalized than those who had a healthy weight. The reasons are not entirely clear, but may stem from the fact that some of these patients were malnourished or frail or had other diseases.
The B.M.I. range associated with the best outcomes, the researchers found, was near the dividing line between what is considered healthy and overweight, consistent with some prior research suggesting that a few extra pounds might help protect people when they contract an infectious disease.
“Exactly why that association exists is currently unknown,” said Dr. Alyson Goodman, a pediatrician and medical epidemiologist at the C.D.C. and a co-author of the study. One possibility is that having a bit of extra fat may provide much needed energy reserves over the course of a long illness.
What the CDC study and this article both fail to address is how doctors, nurses, and other medical professionals put fat patients at risk by refusing to treat them with the same care as thin patients, or ignoring symptoms of something that could be serious until it becomes actually life-threatening. The correlation between “obesity” and contracting COVID-19 seems tenuous at best, but the fact remains that fat patients who do get the virus are more likely to be mistreated by doctors.
Certainly, not every medical professional is so fatphobic as to deny a fat patient a ventilator because it isn’t worth using the equipment on someone they believe is a walking disease already. However, the history of medical fatphobia cannot be ignored or denied. The numbers in the CDC study may be accurate, but there needs to be some consideration of how fat patients were actually treated once they were hospitalized, and whether quicker, better treatment could have prevented some of those deaths.
Now, “obesity” qualifies thousands of people to receive the COVID-19 vaccine ASAP, because the CDC is using BMI as an indicator of risk. This is an extension of how the measurement has been used to shame and blame fat people for decades, but with a key difference: It’s actually helping us. This is the first time I’ve ever been prioritized for a treatment because of my size, and several of my fat peers have said the same.
This puts us in a wildly uncomfortable situation. Most of us have been decrying BMI as absolute garbage for years, because it is. It doesn’t really mean anything, and it ultimately becomes a weapon for medical professionals and insurance companies to deny us comprehensive and compassionate care.
And although rhetoric has shifted in recent weeks, when vaccine programs first began to roll out in the U.S., there was a lot of discussion about who deserved priority appointments, and who shouldn’t “take a dose away from someone more at risk.” Now, the overall message is that everyone should get vaccinated as soon as they can, because the more people who are vaccinated, the better — but because so many fat people know the correlation between weight and COVID-19 isn’t as solid as the CDC claims it is, we felt guilty for even entertaining the idea of getting vaccinated, while many of our loved ones would have to wait weeks or even months.
This, too, requires unpacking. In my experience, whenever a fat person “prioritizes their health,” they’re met with backhanded encouragement from loved ones and unsolicited advice from doctors, all of which comes down to the most “measurable” factor of success: Weight loss. But 95 to 98 percent of diets fail and most people gain back more than they lost; plus, eating and exercise disorders can develop as easily in fat people as in non-fat people — the difference being that the former are praised for running until they puke or getting so hungry they faint, while the latter are put in treatment as soon as someone notices what’s going on.
Therefore, “prioritizing our health” is often code for “trying to lose weight.” If we take other measures, such as seeking medical attention for new or returning or even persistent symptoms, we’re told to shed pounds and the problem will go away. So, when fat people became eligible for the COVID-19 vaccine, some of us had a hard time feeling like we deserved to take those appointments. I struggled to reconcile my ability to get it with the inability of my asthmatic friends to find a single appointment, despite needing multiple inhalers and medications to manage their illness. To make things worse, many fat people — myself included — knew that getting the vaccine because we are fat would invite plenty of anger, resentment, jealousy, and vitriol from others.
When fat people decry BMI as junk science, we’re belittled and mocked. But now that BMI is a qualifying element for the COVID-19 vaccine, people who have long touted BMI as a reason to shame fat people are angry that fat people are getting priority. You can’t have it both ways. Either BMI is an indicator of overall health, which therefore means it’s a fair measurement for a person’s vaccine qualification, or it’s a useless number that’s used to shame fat people rather than actually help them.
Whatever the choice, I think the problem really comes down to this: Fat people are hated for existing, especially if we want to dismantle systemic fatphobia. So when we’re granted access to a vaccine that everyone is chomping at the bit to get, we’re the enemy. We are always, always the enemy. And until that changes, we won’t be treated better when we need to be ventilated in hospitals or when we come to our doctors with concerns about how our lungs feel. We won’t even be allowed to walk down the street without hearing comments from strangers or wondering whether we’ll anger someone on public transportation because they have to sit next to us.
When I told my vaccine administrator that I qualified because of “underlying health issues,” it felt like a lie, because I don’t believe that my size makes me more likely to contract COVID-19. I don’t think BMI indicates anything useful, and I think we need to abolish it as a measurement of health. But the CDC believes that being fat is a health issue, and once I got past the initial feelings of discomfort, I booked a vaccine appointment as soon as I possibly could. If this is the only time in my life that I’ll be prioritized for a medical treatment because I’m fat, I’m not going to miss the opportunity to actually prioritize my health.
If you’re fat and still on the fence about whether or not you should make an appointment: Do it. And if anyone questions you who isn’t literally administering your vaccine, remember that you don’t owe them a damn thing.
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