The COVID-19 vaccine should change the way we think about obesity

I felt guilty, like I was given a gift I didn't deserve simply for existing in the body I've always had. 

The Centers for Disease Control and Prevention (CDC) determines obesity based on BMI, which was never intended to be a holistic metric of individual health. Still, as Johns Hopkins University health disparities researcher Dr. Michelle Ogunwole puts it, "It's better than a coin flip. Obesity does increase your risk of diabetes, hypertension, high cholesterol, and a host of other issues. But there are some people who have obesity, but don't have any other medical problems." 

Personal health is intimate, especially when it comes to something as stigmatized as our weight. I find it hard to articulate, especially on a COVID-19 pre-registration survey, that I can be fat, yet healthy – that weight is one indicator of health, but not the only indicator. When I discovered my priority group, I couldn't help but feel unsettled that I'd get the vaccine sooner than 64-year-olds deemed "normal" by BMI, or immunocompromised people whose conditions aren't considered a priority. 

I talked to health journalist Julia Métraux, 23, who has a rare form of systemic vasculitis. This chronic illness causes blood vessel inflammation, so if she were infected with the coronavirus, she could suffer serious complications. "[The CDC is] not going to look at my type of autoimmune disorder, because it's rare," she explains. "It's frustrating.

I couldn't help but feel guilty that my weight would allow me to get vaccinated sooner than someone like Julia. But as a fat woman, guilt feels familiar. When we talk about who deserves to get vaccinated for a lethal, contagious virus first, it makes sense that people like me would feel conditioned to believe that we've been handed an undeserved gift. But after talking with several public health experts, I learned why obesity is included as a chronic condition. 

Socioeconomic status influences risk for COVID-19

Four days after vaccine pre-registration opened in Philadelphia, WHYY reported that the city will now prioritize the category I fall into ("people under the age of 74 with high-risk medical conditions") in group 1B, rather than 1C. Since 42.4% of American adults are obese, does prioritizing such a large portion of the population defeat the purpose of a priority group in the first place? 

There's a good reason for this decision. "These medical conditions are common in low-income populations and in minority populations – we have higher rates of them here in Philadelphia than elsewhere, it's a more important risk factor here, and this is one way for us to address the racial disparity in COVID mortality here in Philadelphia," City Health Commissioner Tom Farley told WHYY.

Even though this decision promotes equity, it seems that obesity and smoking are being used as a marker for low socioeconomic status, which reinforces a mindset where we continue to treat the conditions of health, race, and income level without nuance, failing to address the systemic injustices that cause such inequity. 

"Obesity may be a proxy, or it may be the result of some social determinants of health impact," says Dr. Bernadette Boden-Albala, Dean of the Public Health Program at the University of California, Irvine. Since the pandemic hit, Dean Boden-Albala has served on a panel of experts informing the State of California's response. 

Dr. Juan Tapia-Mendoza is part of SOMOS Community Care, a network of doctors that supports over 650,000 patients from underserved communities. 

"I'm dubious about the relationship between obesity and COVID-19. The problem goes way beyond waist size," he says. "A lot of these issues happen because of the racial disparity in healthcare that's been going on for centuries."

Dr. Tapia-Mendoza explains that Black people in America are only about 7% more likely to be obese than white people, yet when it comes to COVID-19 deaths, Black people are 2.8x more likely to die. This is because many chronic illnesses – not just obesity – appear more often in historically marginalized communities, and it's not a coincidence.

"Sometimes obesity is viewed with the sense that there's some choice in it. It's the same thing with smoking, that people choose to do that," said Dr. Ogunwole. "But we know that the tobacco and alcohol industries disproportionately target low-income neighborhoods. And we know that the rates of obesity are higher in low socioeconomic status neighborhoods, and among historically marginalized populations like Black and Hispanic populations."

Read more: Tell people the truth: The vaccines are great

Changing how we think about obesity 

COVID-19 exposes our greatest inequities in healthcare, and we see that most clearly when we look at the socioeconomic disparities in coronavirus deaths. But we're also learning that the way we think about obesity is a public health risk in itself. 

"It's a catch-22," adds Dean Boden-Albala. "There is literature out there about folks that are overweight or obese who feel that they have been discriminated against, that they have this pressure on them that results in this cortisol level elevation, which leads to dysfunction, which can lead to increased obesity, decreased immune system response, and of course, making you more prone to chronic disease."

The more I researched, and the more conversations I had with public health experts, the more I began to understand why obesity was listed as a priority. It's not a question of whether we can be fat and healthy – it's a question of how we can make sure that we vaccinate our most vulnerable communities first. Still, I felt undeserving of my prioritized vaccine group. As a young, white person who works from home, should I have left my box unchecked, despite my obesity? 

"Having to ask people to make that choice – 'am I really the most vulnerable here?' – is not as efficacious as if there's a policy or system in place that helps to create the boundaries for that," says Dr. Ogunwole. "Policy is a much more powerful shaper of equity than an individual trying to do the right thing." 

So, even though I know I have the privilege of working from home, I'll take my vaccine once it becomes available. But, I don't think my initial feelings of guilt were unfounded. Not only does the way we vaccinate for COVID-19 reveal socioeconomic inequities, but it also shows us that the medical world doesn't know how to treat fat people in general. Recently, Virgina Sole-Smith wrote about how weight stigma in healthcare leads to poor medical treatment for fat people with COVID-19. In July, the UK prescribed weight loss as an antidote to the spread of COVID-19, further reinforcing the harmful idea that fatness is a personal failure. 

"In my research, the word obesity can have a stigma," says Dr. Ogunwole. "People will readily say, 'I have diabetes.' Nobody would ever think that if they had diabetes, they shouldn't check the box that they have diabetes, since it would take away a spot from someone else."

It's not up to me to choose whether or not I deserve priority vaccination. I'll gladly cooperate to do my part to ensure that we can get everyone vaccinated as quickly as possible. But, when we finally return to some semblance of pre-pandemic life, we can't forget what the coronavirus revealed about the rampant inequities in our healthcare system.