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How Fatphobia Is Leading to Poor Care in the Pandemic

Weight stigma in health care can impact the care people get for Covid-19

Illustration by Anson Chan for Elemental

On October 24, Amanda Martinez Beck of Longview, Texas, told her husband: “You need to take me to the ER.” Their whole family had tested positive for Covid-19 a week earlier — Beck’s husband, Zachary, is an English professor and their best guess is that he brought the virus home from campus, or that Beck picked it up at the community pool where she sometimes swims. Within a few days, Zachary and their four children were all on the mend. But despite prescription albuterol, steroids, and antibiotics, Beck was still coughing and sleeping in a recliner at night because staying upright made it easier to breathe. Around 10 a.m. that Saturday morning, her blood oxygen level was just 92%. (A healthy adult should measure close to 100.) Beck packed a bag and Zachary drove her to their nearest emergency room. He couldn’t stay; the Becks’ children are ages four, five, seven, and eight, and they couldn’t call a babysitter since the family was still in quarantine. So Beck kissed them all goodbye, trying not to panic. “My husband thought he was never going to see me again,” she says now.

Beck had another fear underlying her anxiety about her Covid-19 prognosis: Would she, a fat activist and author of Lovely: How I Learned to Embrace the Body God Gave Me, get the medical care she needed? “Fatphobia is an ever-present concern when you’re dealing with medical issues,” she says.

The coronavirus pandemic has brought the relationship between weight stigma and health into sharp focus. In April, the U.S. Centers for Disease Control and Prevention (CDC) released a report noting that 48% of patients then hospitalized with Covid-19 had a Body Mass Index (BMI) in the “obese” range (compared with 42% of Americans as a whole). A French study published in the journal Obesity around the same time found that Covid-19 patients with a BMI of 35 or higher were more likely to need a ventilator. Most recently, an analysis of 6,916 people with Covid-19 in California found that men with a BMI above 40 had a higher risk of dying from the disease than those with a BMI in the normal range, according to findings published in the Annals of Internal Medicine. A flurry of other medical reports — and an even bigger storm of media coverage — followed.

“There has been an open conversation about whether fat people are worth giving ventilators to, and I don’t think we think enough about the impact of hearing that the worth of your life is up for public debate.”

It’s important to note that none of this research proves that a Covid-19 patient’s high body weight caused their hospitalization, need for a ventilator, or death; it only establishes a tentative correlating relationship. The Annals paper, for example, found no increased risk for folks with overweight or obese BMIs below 40, and no relationship at all for women even at the highest end of the weight range. Nevertheless, “obesity” was added to the collective list of established risk factors for severe Covid-19.

In July, the United Kingdom’s National Health Service launched a call to action urging citizens to “lose weight to beat coronavirus.” California published a draft of guidelines for medical triaging that allowed doctors to prioritize people for ventilators and other resources based on several factors, including weight. And online, memes about quarantine weight gain abounded. Fat advocacy groups began to discuss what all of this meant for the safety of people in larger bodies. “I’m only high risk for Covid in that I’m fat. So I’m not necessarily anymore afraid of [Covid] than anyone else. But I am legitimately very afraid of the health care I would get,” says Aubrey Gordon, the formerly anonymous “Your Fat Friend” blogger and author of What We Don’t Talk About When We Talk About Fat. “There has been an open debate about whether fat people are worth giving ventilators to, and I don’t think we think enough about the impact of hearing the worth of your life debated in public.”

The debate over how to treat people with Covid-19 based on weight stands in stark contrast to the way society talks about other high-risk groups, such as older adults, who are seen as vulnerable and deserving of protection. “Nobody faults your adorable grandmother for getting Covid, but everybody faults a person at a higher body weight,” says Jeffrey Hunger, PhD, an assistant professor of social psychology at Miami University of Ohio who studies health in stigmatized populations. “It breaks on whether you are to blame or not for getting yourself into that high-risk category.” And that blame is pervasive, even though the misconception that body weight is a matter of personal choice and willpower has long been debunked by science.

“We’ve known for years that body weight is incredibly complex,” says Sarah Nutter, PhD, an assistant professor at the University of Victoria in British Columbia, Canada, who studies weight stigma and body image. She points to a 2007 report by the British government, which found that body weight is informed by over 100 different factors and over 300 connections between those factors. “It’s not as simple as calories in, calories out, or how much you move and eat. But that’s the stereotype and the belief that we live by.”

This belief underpins much of the conversation around Covid-19 and weight. It perpetuates a stigma that, in turn, could have real consequences on the survival rates and long-term complications experienced by people in larger bodies who get Covid-19.

Medical fatphobia is not new

That day in the ER, Beck says her weight did not seem to be an issue initially. She brought her own rollator (a mobility device with a bench seat) so she didn’t have to worry about fitting into a waiting room chair, and was soon whisked into an isolated room. Her oxygen level was now down to 78. Beck was admitted and sent to the Covid-19 floor to be put on oxygen support. She says that’s when she began to notice how her weight was subtly influencing the quality of her care. By the time she reached her hospital room, it was after lunch and she was famished. “When the doctor came in to check on me, I said, ‘can I please have a plate of food? I haven’t eaten yet today and I’m so hungry,’” Beck recalls. “That’s really hard to ask when you’re in a larger body.”

Beck had to ask a few more times before a packet of Saltines finally appeared; she wasn’t offered real food until the hospital’s dinner tray arrived several hours later. She acknowledges that the medical team was understandably more focused on keeping her breathing. But Beck, who is in recovery from a restrictive eating disorder and was diagnosed as “borderline” for Type 2 diabetes earlier this year, was worried about the broader health consequences of skipping meals. “I think whenever a fat person expresses a need for food, that is looked at very differently, and as less necessary, than it is for someone in an average or smaller-sized body,” Beck says.

The next issue to present itself was the bathroom: Beck didn’t fit on the standard bedside commode offered in her hospital room, so she had to get out of bed and walk to the bathroom about 15 feet away. “My oxygen tube didn’t reach that far, so I almost passed out doing that,” she says. She explained the situation to a nurse and a larger bedside commode was found. But Beck argues that it shouldn’t be on patients to continually educate providers on these issues. “I could have passed out and nobody would have known right away,” she says. “That’s where this does become a life-or-death thing.”

“If folks in larger bodies have symptoms of Covid-19, but they delay and delay and delay seeking medical treatment because they’re worried about experiencing stigma, maybe that’s why it’s more complicated to treat them.”

The wrong bedside commode and a dismissive attitude toward hunger may sound like unrelated examples. But research shows that these kinds of incidents happen much more frequently to people in larger bodies in all sorts of health care settings. Providers spend less time with patients with high BMIs, and are sometimes even less willing to perform standard care, like pelvic exams at the gynecologist’s office. A 2011 study found that medical students were more likely to blame people for conditions like respiratory distress if they were in a bigger body, and tended to prescribe weight-loss strategies, rather than symptom management. And in 2019, Nutter surveyed 400 Canadian doctors and found that 24% admitted they were uncomfortable having friends in larger bodies, and 18% felt disgusted when treating a patient with a high BMI.

Blair, a social worker and mother of two living near Omaha, Nebraska, who asked to use only her middle name, says that she’s all too aware when a health care provider treats her, a fat person, with disgust. She was diagnosed with Covid-19 on November 1 after seeing a doctor to report that she had lost her senses of taste and smell. In response, she recalls him saying, “‘You don’t look like someone who eats a lot of fruits and vegetables, but you really need to focus on that right now because your body needs it.’” Blair was humiliated. “He didn’t know anything about my food choices or that I’m an intuitive eater,” she says. “But I didn’t stick up for myself because I was feeling so poorly physically. I just kind of took it.”

Later that night, Blair woke up struggling to breathe and called an ambulance to take her to the hospital. “When I told [the EMT] my weight, he kind of sighed,” she recalls. “And when it came time to get into the ambulance, they really didn’t help me at all.” Even though she was in respiratory distress, Blair found herself climbing the stairs to the ambulance. “I don’t want to be overly sensitive, but I felt like I wasn’t super cared for,” she says. “I felt like they were judging me like I wasn’t sick enough.”

That this attitude so pervasive in health care is dangerous. “Many of the studies on weight bias and medicine include some version of the sentence ‘doctors are just like the rest of us,’” says Gordon. “But they’re also in these wild positions of power. So they’re not necessarily trying to do bad things — doctors are doing heroic things this minute! But they have these baked-in biases that we all have, and that their training hasn’t ever called into question.” And because weight stigma often manifests in these stray comments, sighs, and seemingly small humiliations, it can be difficult for vulnerable patients to push back.

The lack of accountability for this fatphobia also impacts how research on weight and health gets done: None of the studies linking weight to Covid-19 complications have looked at whether a person’s experience of stigma impacted their quality of care, let alone their baseline health, even though there’s evidence that living with chronic weight stigma causes people in higher weight bodies to avoid doctors, and compromises their care in other ways. “Even if a relationship exists between weight and severe cases of Covid-19, we should be looking at whether health care avoidance is an explanation for this,” says Hunger. “If folks in larger bodies have symptoms of Covid-19, but they delay and delay and delay seeking medical treatment because they’re worried about experiencing stigma, maybe that’s why it’s more complicated to treat them.”

Hannah, a photographer in Brooklyn who asked to have her name changed, says that’s exactly what happened to her. “I’m sure I had Covid-19 but I didn’t go for a test because I was afraid they would weigh me,” she says. Hannah lost her sense of taste and smell at the end of March, but the doctor’s office was the last place she wanted to go. “I’m 5’1” and 240 pounds. Every time I go for a checkup, they tell me to lose weight even though I’m healthy,” she says. “I’m trying to work on my relationship to food and being told to diet does not help.” She sought no treatment, self-quarantined, and recovered — though nine months later, her taste and smell have yet to fully return.

The ventilator debate

Three days after she was admitted to the hospital, Beck was transferred to the Intensive Care Unit and intubated. She doesn’t remember how it happened, but she stayed on the ventilator, and heavily sedated, for over two weeks. “I missed Halloween, I missed the election, I only existed in a dream world,” she says. But even in her dream state, Beck was aware of her weight. “In my dreams, I kept feeling very paranoid about people trying to make me smaller,” she says. In one of her more empowering dreams, she befriended Lizzo and they performed the cold open to Saturday Night Live together. In others, she was already dead.

This dramatic push-pull of her subconscious makes sense because while she was fighting for her life, Beck was also up against what she and other activists say is the biggest fear in the fat community right now: That if they become severely ill with Covid-19 in an area with medical supply shortages, they will not receive lifesaving equipment, such as ventilators, because of their weight. At press time, there was no published data to indicate how commonplace this sort of medical rationing is or may become as the pandemic reaches its winter peak and hospitals are once again overcrowded in many parts of the country. “This is a really important question but so hard to document,” says Rebecca Puhl, PhD, a weight stigma researcher and deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut. “If a doctor chooses one patient over another for a ventilator, that probably won’t be written into the report. So there’s a layer of stigma here that may be present but is very hard to monitor or document in any way.” The true scope of ventilator triaging may only become clear retrospectively, Puhl notes, when researchers are able to analyze data on Covid-19 death rates.

But there is this reassuring news: When California initially announced their triage guidelines, fat and disabled activists responded swiftly with the #NoBodyIsDisposable campaign, arguing that weight, along with physical and intellectual ability, should not factor in prioritizing lifesaving medical equipment and resources. “These triage protocols are unfair and unlawful,” says Brandie Sendziak, one of the campaign’s co-founders and a supervising attorney at the Independent Living Resource Center in San Francisco, who describes herself as both fat and disabled. “Comorbidities, especially those that have a disproportionate impact on people based on race, gender, or size, should never form the basis of medical rationing. These are not acceptable losses.” Sendziak and her colleagues at other disability rights organizations submitted comments on the California Department of Health’s draft guidelines and continued to advocate over the course of last spring. When the final guidelines were published in June 2020, they specifically advised that “healthcare decisions, including allocation of scarce resources, cannot be based on […] weight/size” as well as more than a dozen other personal characteristics such as age, race, disability, and ability to pay for medical services.

Because our culture views weight as mutable, it’s considered acceptable to expect fat people to change themselves to suit the system — but it’s supposed to be the other way around.

Sendziak was thrilled with the victory but still worries about the protocols in place in other states, as well as how any individual doctor may react. “What happens if a health care provider reads a magazine article about how Covid-19 impacts fat people and decides hey, this patient won’t do as well as their thin counterpart, so we’ll give our resources to the thin patient instead,” she says. But Puhl says there is also the possibility that bias will, ironically, work for patients in this scenario: “It’s possible that knowing these patients are at higher risk means doctors will do more to help them,” she says. The problem, of course, is that this approach still lets bias drive health care decisions.

The unexpected consequences of Covid-19

After 16 days, Beck was stable enough to come off her ventilator — or, more accurately, she removed it herself. “I had removed it once a few days earlier when I woke up just enough to not know where I was or why there was a tube down my throat,” she says. The nurses restrained her hands so she couldn’t remove it again — so Beck pulled it out with her feet. “Don’t let anyone tell you fat people aren’t flexible!” she laughs. Her recovery was far from instant, though; she spent two more weeks in the hospital, then was transferred to a rehab center to work on gaining strength and relearning how to walk.

Here again, she found herself in the position of needing to educate staff about the needs of their fat patient. One night, she fell in the bathroom. “I thought I had been given permission to go by myself but I hadn’t,” Beck recalls. “I didn’t hurt myself, but there I was, bare-bottomed on the floor. And they had no idea how to get me up.” Beck’s voice was still weak from intubation and she didn’t have the strength to lift herself. The staff tried putting a sheet under Beck to pull her up, but it didn’t work. Finally, they called 911 and two paramedics came to rescue her. “I’m aware that people may feel embarrassed for me but there’s nothing for me to be ashamed about,” Beck says. “People fall in the hospital all the time and they didn’t have a protocol for how to handle it with someone my size.” (The hospital and rehab center did not respond to request for comment).

Because our culture views weight as mutable, it’s considered acceptable to expect fat people to change themselves to suit the system — but it’s supposed to be the other way around. Health care is supposed to meet patients where we are, not where we might be someday, maybe. And even in a pandemic, when health care providers and systems are stretched past their limits in every possible way, that has to still be true. Even if the science eventually shows a more concrete link between weight and Covid-19 complications, nobody can lose weight fast enough to make sure they don’t catch the virus at the grocery store today. And they deserve comprehensive care no matter what. “Even if you believe we’re unhealthy; even if our bloodwork and other records show that we are not in perfect health,” says Gordon. “Do we want to be the kind of person who denies people their basic needs because they don’t meet your definition of healthy enough?”