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August 14, 2009


Filed under: The Fat's in the Fire — Francesca @ 10:56 am

From the New York Times magazine of this weekend:

Two years ago, the Cleveland Clinic stopped hiring smokers. It was one part of a “wellness initiative” that has won the renowned hospital — which President Obama recently visited — some very nice publicity. The clinic has a farmers’ market on its main campus and has offered smoking-cessation classes for the surrounding community. Refusing to hire smokers may be more hard-nosed than the other parts of the program. But given the social marginalization of smoking, the policy is hardly shocking. All in all, the wellness initiative seems to be a feel-good story.

Which is why it is so striking to talk to Delos M. Cosgrove, the heart surgeon who is the clinic’s chief executive, about the initiative. Cosgrove says that if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people.


This extra weight has caused a sharp increase in chronic diseases, like diabetes, that are unusually costly. Other public-health scourges, like lung cancer, have tended to kill their victims quickly, which (in the most tragic possible way) holds down their long-term cost. Obesity is different. A recent article in Health Affairs estimated its annual cost to be $147 billion and growing. That translates into $1,250 per household, mostly in taxes and insurance premiums.

A natural response to this cost would be to say that the people imposing it on society should be required to pay it. Cosgrove mentioned to me an idea that some economists favor: charging higher health-insurance premiums to anyone with a certain body-mass index. Harsh? Yes. Fair? You can see the argument. And yet it turns out that the obese already do pay something resembling their fair share of medical costs, albeit in an indirect way. Overweight workers are paid less than similarly qualified, thinner colleagues, according to research by Jay Bhattacharya and M. Kate Bundorf of Stanford. The cause isn’t entirely clear. But the size of the wage difference is roughly similar to the size of the difference in their medical costs.


The solutions to these problems are beyond the control of any individual. They involve a different sort of responsibility: civic — even political — responsibility. They depend on the kind of collective action that helped cut smoking rates nearly in half. Anyone who smoked in an elementary-school hallway today would be thrown out of the building. But if you served an obesity-inducing, federally financed meal to a kindergartner, you would fit right in. Taxes on tobacco, meanwhile, have skyrocketed. A modest tax on sodas — one of the few proposals in the various health-reform bills aimed at health, rather than health care — has struggled to get through Congress.

Cosgrove’s would-be approach may have its problems. The obvious one is its severity. The more important one is probably its narrowness: not even one of the nation’s most prestigious hospitals can do much to reduce obesity. The government, however, can. And that is the great virtue of Cosgrove’s idea. He is acknowledging that any effort to attack obesity will inevitably involve making value judgments and even limiting people’s choices. Most of the time, the government has no business doing such things. But there is really no other way to cure an epidemic.

Francesca says:

1-  If it is OK to discriminate against people who smoke, then logically it might be OK to discriminate against people who never, ever exercise, or who eat 3 doughnuts a day. It does not logically follow that it is OK to discriminate against people based on their BMI, any more than it is not OK to discriminate against a person (for a job where they want non-smokers) on the basis of that person having yellow teeth and wheezing. Maybe they drink a lot of coffee and have a cold. If one wants to argue that it’s OK to judge people based on their personal behavior, then judge based on the behavior.

2- Studies have shows that shaming fat people just makes them eat more. Francesca realizes that  shaming others is extremely tempting in all sorts of circumstances, and self-righteousness feels terrific (?), but as a matter of public policy we may as well stick with avenues that have not been proven not to work, eh?

3- Francesca is all for healthier government-funded school meals;  regulations that would make fruits and vegetables and whole-grain, chemical-free food easily accessible and affordable for everyone; more, better school gym programs (though she asks that as long as we are at it, we eliminate humiliating practices like kiddy captains picking their own teams, or, as was the case for a friend of mine from Connecticut, a school requirement — this at a public high school– to take co-ed water polo); incentives to help people exercise, etc. Heck, tax cola if you want; no one needs cola. Knock yourself out, policy makers. But don’t presume to know anything about my health status or my lifestyle based only on my weight.


  1. f I were this guy’s competitor, I would think, “Cool! He’s ignoring a lot of talented, smart, hardworking people.”

    If I were this guy, the next step would be not hiring people who drink. Ever. Don’t hire the skinny-fat woman who does coke to kill her appetite or sticks her finger down her throat after every meal and has no muscle tone. What about the pregnant woman? She’s going to cost us money! Hey! And you, with the sick baby. No way. We can’t afford you. Why did you let your child be born with brittle bone disease, anyhow? That’s so irresponsible. So expensive.

    So yes — let’s give up our freedoms so the government, which, “Most of the time, … has no business doing such things” can tell us how to live. After all, only We The People can cure an epidemic.

    Comment by class factotum — August 14, 2009 @ 11:05 am

  2. You know what they say about surgeons, Dr. Cosgrove……they take up that medical discipline because all of their patients are asleep. They are notoriously lacking in anything that passes for people skills.

    I for one would be happy if hospitals required their physicians, pharmacists and nurses to submit to pre-employment and random drug & alcohol screening. I’m willing to bet big money that people don’t come close to realizing how many health professionals are practicing while under the influence of drugs and alcohol. Addicted health care professionals are a huge problem in the United States. I wowork in this field and I see the havoc they wreak every day. They divert medication that should go to patients, commit medical errors (like amputating the wrong limb), disrupt the other medical staff members, open healthcare facilities up to expensive litigation, cost patients their lives and most of these abusers go undetected. When you observe this phenomenon in the real world, Dr. House is no where near as amusing as he is on TV. So Dr. Cosgrove, physician heal thyself.

    Comment by gemdiva — August 14, 2009 @ 12:14 pm

  3. Drug tests for people who work in environments where being drugged can be dangerous to other people — transportation, manufacturing, medicine — are a good idea. Taking drugs is a choice and can have a direct impact on your job performance and workplace safety.

    Your weight, your blood pressure, your diabetes — there are not so many instances where these make you a bad fit for a job. What you weigh is not your employer’s business. It doesn’t make you any less competent as a loan officer, a programmer, a journalist, a physician. This guy is way off base.

    Comment by class factotum — August 14, 2009 @ 2:02 pm

  4. We are in complete agreement. The other thing that really bugs me is that the same insurance companies who bemoan the fact that so-called “obese” people are driving up the price of healthcare, basically would rather pay for insulin and blood pressure meds (not to mention paying for strokes, amputations and heart attacks) rather than providing assistance to people who want to pursue a healthier life style. Whether it be nutritional counseling, behavioral counseling or providing access to exercise venues or a weightloss program like weight watchers. I am not advocating any of this, but for those who do want/need it, let the insurers put their money where their mouth is. OK, I’m gettin’ off my soap box now.

    Comment by gemdiva — August 14, 2009 @ 5:20 pm

  5. It’s hard to know where to begin, isn’t it? Frankly, I’m so tired of hearing about the costs of health care. Guess what? Every one of our economic peers gets it and pays for health care for its citizens. The big mistake is believing that health care should be a money-making business. Today (and always) it’s fat people who are the problem, but if by some miracle the focus shifted off of us, believe me, there would be talk about how expensive cancer (or depression, or whatever) is.

    The most dangerous thing personally is that I’m never shocked or surprised when this dreck gets re-hashed. But my dismissal may backfire one day when I realize that they’re really serious and the discrimination not only gets worse, but becomes law.

    Comment by Mrs. Hendricks — August 14, 2009 @ 5:26 pm

  6. I think reason why “obese people” get paid less is because they don’t look as attractive. And it has been written over and over again by psychologists that people are just more inclined to pay more attention to attractive looking individuals.

    Comment by Rid — August 14, 2009 @ 6:08 pm

  7. People never fail to disappoint. Now then, if you’d like to discuss people with God complexes and their clear belief that they know what is best for the world…

    Can we put a moratoriam on blow hards?

    Comment by Melissa — August 14, 2009 @ 7:31 pm

  8. I thought the reason one wouldn’t hire smokers is due to the fact that smoke particles cling to them long after they’ve extinguished the cigarette. Foolish, naive me.

    Comment by megaera — August 15, 2009 @ 2:48 am

  9. megaera – but the fatties leave fat particles in the air! They’ll just up and fat all over you!

    This illustrates for me one of the many problems with the ‘epidemic’ paradigm* that’s being used. It’s not about ill-health, is it? ‘Obesity’ is a neat way to move people’s health problems into the realm of personal responsibility – where we like it to be. It’s far easier to have a health crisis based on some nebulous group of People What Dun Brought It On Themselves and can be punished for it, and not dwell on those other unpleasant facts about how any of us – regardless of how much yoga we do and organic beat sprouts we eat – can get sick.

    Mikhaela B. Reid has a cartoon about the current health system debate which I think gets into this underlying fear –

    Not that I want to drag Francesca’s excellent point into a political argument about the US health care system, I swear. It’s just that I read that, then saw this post, and saw an overlap.

    *I apologise, ok, I’m only midway through my coffee, and silly grad student language is all I gots.

    Comment by Margo — August 15, 2009 @ 5:25 am

  10. If Cleveland Clinic won’t hire me (size 14 and dropping, BMI of 30, technically “obese”, though I bench 120), and health insurers want to charge me more, then I shouldn’t have to pay school taxes. After all, I’m childfree; I’ll never use the system in the town where I live.

    Which is a ridiculous argument. There are some things that are beneficial for society as a whole, like Social Security, Medicaid/-are, and free public education. If I were queen of the world, a universal, publically-funded health insurance program would be paid for, but paid for in a progressive way according to income, not according to risk factors.

    Because, after all, even the person with the world’s shortest list of risk factors can be flattened by a bus unexpectedly.

    Additional high-five to Gemdiva: I’m a registered nurse and I work, tangentially, for a state entity. I was hired seven years ago and tested then. Although my employer touts its random, unannounced drug/alcohol screens, I have *yet* to be tested. In a 140-bed hospital, there aren’t that many of us; you’d think they’d get around to me eventually.

    Comment by Jo — August 16, 2009 @ 6:02 pm

  11. And from the other end of that very same magazine, in Lives, we have this:

    “The partner, a chic young woman, blond, extremely thin, was carrying a fat book called “L’Anorexie.” Judging by her own size, I wondered if it was a guide, but she explained that she was training to help people with eating disorders. Bulimia and anorexia were severe problems in France, she told me: women, and increasingly men, are prey to a cultural mystique that proclaims they must be both fashionistas and foodinistas. Bulimia in particular is widespread, she said, and people smoke heavily to suppress their appetites.”

    Booga booga OBESE AMERICANS WORST THING EVER! Or, you know, not.

    Comment by Slim — August 17, 2009 @ 4:34 pm

  12. What a lovely world we live in. I can no longer be discriminated against for being a woman or for being Jewish. I can apply to go to school or for jobs that would have been closed to me forty years ago. I can even have a baby out of wedlock or have an abortion with out committing career or social suicide.

    However, I can now be discriminated against for my weight. I can apply for the job that I am qualified for and be called in for an interview. I can even have a good interview, but if they don’t decide to go with me is it because they found someone more qualified or am I not a good fit or do they see my thighs as a liability?

    Comment by Sara A. — August 17, 2009 @ 7:22 pm

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