Fat Hatred in the New Yorker

[TW for fat hatred]

I love the New Yorker articles that Atul Gawande writes.  I love them so much and was so affected by his one on hospice care last year that I wrote a post about it, pointing people to his work.  So, last week, when I saw that there was a new Gawande piece in the NY about health care, I was thrilled.

[UPDATE: Full article is now available online so that you can read it for yourself if you don’t have a subscription.]

Here is the abstract of the piece, “The Hot Spotters: Can we lower costs by giving the neediest patients better care?,” from the NY website:

Medical report about innovative approaches to reducing health-care costs.

Writer tells about Jeffrey Brenner, a physician in Camden, New Jersey, who has used data mining and statistical analysis to map health-care use and expenses. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients. In his experience the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care. If he could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs.

Describes his work with those high-use patients, which led to the creation of the Camden Coalition of Healthcare Providers. By late 2010, his team had provided care for more than three hundred people on his “super-utilizer” map. The Camden Coalition has been able to measure its long-term effect on its first thirty-six super-utilizers. They averaged sixty-two hospital and E.R. visits per month before joining the program and thirty-seven visits after—a forty-per-cent reduction. Their hospital bills averaged $1.2 million per month before and just over half a million after—a fifty-six-per-cent reduction.

These results don’t take into account Brenner’s personnel costs, or the costs of the medications the patients are now taking as prescribed, or the fact that some of the patients might have improved on their own (or died, reducing their costs permanently). The net savings are undoubtedly lower, but they remain, almost certainly, revolutionary.

Writer visits the offices of Verisk Health, a data-mining company, which supplies “medical intelligence” to organizations that pay for health benefits. Besides the usual statisticians and economists, Verisk recruited doctors to dive into the data. One of those doctors, Nathan Gunn, guides the writer though the way data mining can be used to identify the most frequent users of health-care facilities and reduce their costs.

Writer also visits the Special Care Center, a clinic in Atlantic City, which houses an experimental approach to primary care. Tells about the Center’s leader, Rushika Fernandopulle, and the intensive outpatient care for complex high-needs patients that the Center provides. In addition to physicians and nurses, the Center employs eight full-time “health coaches,” who help patients manage their health. Fernandopulle carefully tracks the statistics of the Center’s twelve hundred patients. After twelve months in the program, he found, their emergency-room visits and hospital admissions were reduced by more than forty per cent. Surgical procedures were down by a quarter. The patients were also markedly healthier. Considers difficulties in implementing these and other innovative ideas on a larger scale, including possible opposition from insurance companies and the health-care lobby.

One thing I really appreciate about Gawande’s work with health care is that it doesn’t feel preachy.  It feels like he is simply telling you things (which I know doesn’t mean he isn’t preaching but it doesn’t read that way – he isn’t trying to tell ME how to fix health care through my personal, individual actions.  He is talking about the entire system and often is talking mainly about doctors.).

This article is about fixing health care by focusing more attention on the neediest patients by  training doctors to treat their patients holistically and encouraging a system that allows doctors to do that.  He advocates for better coverage for everyone because the people who hurt the most when health care goes away are the people who are already hurting, and then they just tax the system more and more as they end up repeatedly going to the ER and continuing in a cycle that either goes nowhere or down.

The patients in this article are painted as individuals, each with their own complicated sets of reasons that they need so much treatment and so spend or cost so much money on health care.  Gawande doesn’t judge them, at least in my opinion.  They all had different problems but there is no attempt to blame them, to point to a single overriding factor, or to draw major conclusions across patients, except to talk about the ways that reducing health care coverage or giving people who use the most health care dollars more attention affects the larger system (the former in a bad way, the latter in a good).

Specifically, there is no OBESE PEOPLE RUIN THE SYSTEM BY BEING SO DAMN UNHEALTHY!  Which, given the state of our discourse surrounding health and what counts as healthy, one could easily go there, or at least could expect an article about the high costs of health care to go there.  But the article isn’t about that.  It doesn’t address obesity or any other disease EXCEPT when it matters to telling a single person’s story.  And, when it comes to weight, there are two people in the article whose weight is mentioned, one being referred to specifically as having “obesity”.  That’s out of a whole lot of people and patients.

Here, let me just write what Gawande wrote about the first of the two people:

The first person they found for him was a man in his mid-forties whom I’ll call Frank Hendricks.  Hendricks had severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse.  He weighed five hundred and sixty pounds.  In the previous three years, he had spent as much time in hospitals as out.  When Brenner met him, he was in intensive care with a tracheotomy and a feeding tube, having developed septic shock from a gallbladder infection.

Brenner visited him daily.  “I just basically sat in his room like I was a third-year med student, hanging out with him for an hour, hour and a half every day, trying to figure out what makes the guy tick,” he recalled.  He learned that Hendricks used to be an auto detailer and a cook.  He had a longtime girlfriend and two children now grown.  A toxic combination of poo health, Johnnie Walker Red, and, it emerged, cocaine addition had left him unreliably employed, uninsured, and living in a welfare motel.  He had no consistent set of doctors, and almost no prospects for turning his life around.

After several months, he had recovered enough to be discharged.  But, out in the world, his life was simply another hospitalization waiting to happen.  By then, however, Brenner had figured out a few things he could do to help.  Some of it was simple doctor stuff. […] He teamed up with a nurse practitioner who could make home visits to check blood-sugar levels and blood pressure, teach Hendricks about what he could do to stay healthy, and make sure he was getting his medications. […]

He told Hendricks that he needed to cook his own food once in a while, so he could get back in the habit of doing it.  The main thing he was up against was Hendrick’s hopelessness.  He’d given up. […]

I spoke to Hendricks recently.  He has gone without alcohol for a year, cocaine for two years, and smoking for three years.  He lives with his girlfriend in a safer neighborhood, goes to church, and weathers family crises.  He cooks his own meals now.  His diabetes an congestive heart failure are under much better control.  He’s lost two hundred and twenty pounds, which means, among other things, that if he falls he can pick himself up, rather than having to call for an ambulance. […]

And ordinary cold can still be a major setback for Hendricks.  He told me that he’d been in the hospital four times this past summer.  But the stays were a few days at most, and he’s had no more cataclysmic, weeks-long I.C.U. stays.

And that’s all Gawande says about him.

He mentions many other patients: the woman with chronic headaches, the man who is going blind from diabetes, people suffering from coronary-artery disease, someone whose kidneys are failing.

The other person whose weight Gawande specifically notes is an Indian immigrant.  He describes her as having “obesity” along with overall poor health, diabetes, and congestive heart failure.  But when talking about her recovery and her improved health, he doesn’t mention her weight.  She does yoga, monitors her blood sugar, and had changed her diet – those things he tells us.  We are never told if losing weight is a specific result or cause of these changes.  Because that is not what this piece is about.

Gawande does not dwell on weight.  He mentions it three times (from my count, which, I must admit is a bit cursory) and without EVER saying that obesity is the problem taxing the system.  Never.

So, why, then, WHY is this the picture with the article?

As you can see, it’s right there, at the beginning. It is the FIRST thing your eyes go to, before you read the title, the subtitle, the author’s name. You can’t help but think that you are about to read an article about how fat people cost the health care system (and by extension, all of society) a whole lot of money.

But that isn’t what you read. Gawande never says that.  He doesn’t even imply it.  So WTF, New Yorker? I imagine that Gawande had no part in picking this picture. I don’t know.

What this does display is the ingrained way in which our society immediately equates someone who is overweight with being unhealthy. The editor(s) of the New Yorker picked this picture because it tells a whole story in itself and they were purposefully using it for that reason.  If that person had been thing, wrapped in a mummified bandaged way with that pricetag around their neck, we would think, “Oh, did they have cancer?” or  “I wonder what happened to that person.”  Instead, we look at this image and we think, “Of course.”  Of course, a fat person would tax our system.  They are unhealthy and must go to the doctor a lot.  Often they are lazy and that also leads to even more health issues.  If fat people would just stop being fat, health care would not cost so much.  As you begin to read you think, Atul Gawande is going to tell me all about the fat unhealthy people.  Which he doesn’t.  But that doesn’t matter.

As my partner pointed out to me, the picture sets you up to visualize EVERYONE in the article who is chronically unhealthy as being overweight, even though Gawande doesn’t tell us that they are.  I have no other way to say this than: that is fucked up.  And sad.

This picture both works off our often unconscious characterizations of fat people as unhealthy (fat hatred is part and parcel of our modern society) and creates it anew.  We make people in the article obese in our minds without needing any of Gawande’s words to do that for us.  We equate their healthy rebounds with losing that weight even when that isn’t mentioned.  The picture plants that idea and our already formed beliefs buttress it.  Maybe we would still have thought such things but there’s no escaping it when you see this picture before ever reading a word.

It’s a bad, bad picture.  It is fat hatred that is both blatant and subtle – you can’t miss the image but you also don’t see the work that it is doing.

Shame on the New Yorker.  Because you can’t take that back.  That picture will forever be there, that man forever looking out at me, whenever I go to read this article.  And this article, it will never be about obesity and health.  Two things that are unrelated except for society’s fat hatred, brought to you by the NY.  Awesome.

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