It Was Never About Health
Bariatric surgeries are being pushed on patients at a major New York hospital; the health outcomes are shocking, but not, in the end, surprising.
Content warning for fatphobia, medical trauma, and death.
One patient, Jasmine Nieves, 30, wound up in agony after her surgery; when she called for help repeatedly, nobody at the clinic answered. A month later, she passed out on a couch, and her sister called an ambulance. A CT scan revealed fluid pooling in her abdomen. She required emergency surgery, and spent the next year in and out of hospitals, at one point requiring a feeding tube.
Another patient, Magaly Rojas, 43, had her spleen punctured. She ended up in a medically induced coma for a month; afterwards, she could no longer control her bowels, and is out of work because of it. She and her three young children now face losing their apartment.
A third patient, Soraya de Oliveira, 53, ended up with a belly full of blood; despite two emergency surgeries, she died two days later.
These patients had all received bariatric surgery at Bellevue Hospital, a major New York public hospital. Such elective procedures, designed to shrink people’s stomachs to a small fraction of their former size, typically induce rapid weight loss. They are also known to lead to serious health repercussions, and require follow-up interventions—including surgeries and hospitalizations—in one third of cases within a five-year timeframe. And many patients subsequently experience nutritional deficiencies (including anemia and scurvy), gallstones, hernias, intestinal leakage, bowel obstructions, and serious bone loss.
Perhaps most disturbingly of all, studies show that people who undergo bariatric surgery are at least twice as likely to commit suicide as their counterparts who do not. Although the reasons for this are not yet fully understood, psychologists and other experts emphasize the importance of patients receiving careful screenings and in-depth counselling prior to these surgeries.
That makes The New York Times investigative report published yesterday into Bellevue’s shoddy practices—with multiple corners cut—rightfully shocking. One patient who was operated on was pregnant, after the facility forgot to check her test was negative. She was subsequently counselled to consider an abortion, since her body might not be able to supply the necessary nutrients to a developing fetus. Other patients report receiving no more than ten minutes of mental health counselling, and just one information session, prior to their scheduled surgery. Moreover, patients were rushed in and out of ORs, with the hospital on track to perform some 3000 bariatric surgeries this year. There are even reports of patients in the ER with minor stab wounds, broken bones, and severed fingers who could not be operated on because there was no OR space left for them. A shattered rib surgery was postponed until the next day, for example.
In its defense, Bellevue points out that its rate of complications is on par with national averages for bariatric surgeries, and its mortality rate—with two patients, including de Oliveira, dying—actually below the national average. Indeed, one in 200 patients die following gastric bypass surgery according to some estimates.
It’s a both/and situation. Bellevue’s practices are shocking. And the bar for such interventions on patients, and the standard of care for them, is often far, far too low. Moreover, there’s a pressing question about whether such drastic measures are needed in the first place: some Bellevue patients were not even clinically obese, with a BMI of below 30, prior to the surgery. This would put them in the “overweight” category, which is, statistically speaking, the healthiest category to be in, at least in the sense of having the lowest mortality rates. Even moderately obese people have no greater mortality risk than “normal”-weight people either.
All too often, patients’ potent fear of fatness—and the supposed health ill effects of it—are being exploited for no other reason than to drive a tidy profit. And that profit stands to be at least 34 million dollars this year for Bellevue, according to the New York Times report’s conservative estimates. As the reporters, Jessica Silver-Greenberg, Sarah Kliff and Aimee Ortiz, write:
The bariatric department has an incentive to move fast. The hospital receives at least $11,000, and sometimes much more, for most weight-loss surgeries. And unlike many doctors at Bellevue, who get paid flat salaries, the bariatric surgeons earn more money when they perform more operations.
“It’s all about the numbers,” said Dr. Carmen Kloer, who worked with Bellevue’s bariatric department as a medical resident before quitting in October. “They are just churning through cases.”
Much of the resulting profit is funded by taxpayer dollars, with Bellevue disproportionately serving a poor population on Medicaid. Some of its bariatric surgery patients were even recruited from New York City’s Rikers Island jail complex, for whom maintaining the required diet after the surgery—featuring small, frequent, protein-rich meals—was pretty much impossible. Two such patients told The New York Times that they regretted the surgery, and that they’d become malnourished. As one of them put it, the tactics used to push the surgery on him reminded him of those he’d used himself as a drug dealer: the doctor had told him it was his last shot and that, if he didn’t go through with the procedure, he’d be sent back to jail immediately. The pain another endured ended up being worse than after he was hit by a car and had to have his arm amputated above the elbow.
The Times report suggested that the bariatric surgeries had been rushed partly by cutting down on pain medication for patients, some of whom had been woken by having their bellies pinched and slapped afterward by one of the surgeons. Insult was thus added to what, for some patients, turned out to be grave injury.
Shocking as this report is, we shouldn’t lose sight of how the profit motive in medicine can drive untoward outcomes and fuel unscrupulous providers. Patients who are particularly vulnerable—in being disproportionately poor, less educated, and incarcerated, in some cases—are made all the more so through the exploitation of their understandable fear that their fatness is a death sentence, and they need to lose weight urgently. In reality, the science on this matter indicates something different. Major long-term studies show that, when fat patients lost weight the old-fashioned way (that is, through diet and exercise), they did not reap the health benefits it was assumed would flow from weight loss. To the surprise of the researchers, this even held in populations with type 2 diabetes. And, as highlighted above, mortality risks for overweight and even moderately obese people are no higher than for their normal-weight counterparts.
True, very heavy people do have greater mortality risks, along with very thin ones. But correlation does not entail causation, and we shouldn’t assume that being very fat (or, again thin) is the decisive cause of ill health here; oftentimes, the causality may be complex or run in the other direction. Moreover, we know that weight cycling—losing and gaining weight repeatedly—carries independent health risks. And this is what will happen to many of the people who receive bariatric surgery; about a third gain a significant amount of the weight back. (The same holds for those who take the burgeoning new class of weight loss drugs, such as Ozempic or Wegovy, and then stop taking them at some point—as have and likely will the vast majority. But that’s another story.) The resulting weight cycling does measurable harm, in damaging people’s cardiovascular systems, metabolisms, immune health, and even increasing their risk of developing diabetes.
This raises the question: why are we setting people up for failure, both in terms of their long-term weight loss goals, and even their health and overall well-being?
This is not a rhetorical question: it has a concrete answer. Fatphobia, the irrational, immoral downranking of fat bodies makes us far too liable to assume that fatness is automatically unhealthy, and that weight loss is always the answer. And we persist in pushing for it, and being pushed into it, often at the expense of better health outcomes. That enormous profits can be garnered by doing so should raise our collective alarm bells. And in the case of hospitals like Bellevue, patients’ vulnerabilities and fears of losing control of their bodies are simply being mined for economic gain. It may come at the expense of their living well—or even at all, in some cases.
Where’s all the outcry about this from the transphobic “activists” who want to prevent bodily “mutilation”? Bariatric surgeries are increasingly being pushed on children as well, yet we haven’t heard a peep from that crowd. It’s almost as though their “concern” isn’t actually about the health of patients. . .
So powerful to read about these systemic abuses against fat bodies. So cruel. Thank you for writing into these horrors, Kate.