key: cord-253567-a7qg8546 authors: Friedman, Danielle T.; Martin, Matthew J. title: Comment on: Should Bariatric Surgery be Offered to Prisoners? date: 2020-08-11 journal: Surg Obes Relat Dis DOI: 10.1016/j.soard.2020.08.001 sha: doc_id: 253567 cord_uid: a7qg8546 nan The authors of this opinion piece raise the thought-provoking argument that in order to ensure equity in healthcare for imprisoned persons, and to provide optimal treatment for prisoners with obesity and its health-related comorbidities, access to bariatric surgery should be provided for qualifying individuals within the prison system. 4 They propose that candidates might be identified during routine health care within the penal system and referred to a bariatric program, the logistics of which would vary based upon the resources available within an individual prison and the affiliated bariatric surgery program. Some may rely on consultation with outside psychiatrists and dieticians, for which telehealth could play a vital role, while other facilities may offer services from in-house staff, supported by such existing recommendations as the Federal Bureau of Prisons Nutrition Management after Bariatric Surgery guidelines. In the era of COVID-19, with many essential clinical encounters being transitioned to telehealth media, the suggestion that bariatric appointments could occur digitally across prison walls is hardly farfetched. The authors acknowledge that the correctional system is generally underfunded and understaffed, but suggest that some of the cost to the taxpayer may be offset by the resolution of obesity-related comorbidities and therefore reducing the significant costs associated with their treatment. Most importantly, the authors point out that incarcerated individuals are disproportionately affected by obesity and its comorbidities. What's more, incarceration may provide their first access to adequate healthcare. This underlines the critical argument for bariatric surgery in an imprisoned population, despite its challenges: providing these patients access to the most effective treatment for obesity and its comorbidities could help to correct dramatic racial and socioeconomic healthcare disparities impacting prisoners. As noted in a 2017 Lancet study, "Incarceration has become common for poor men from ethnic minorities," J o u r n a l P r e -p r o o f especially non-Hispanic Black men. 6 This is the same population that suffers the highest rates of obesity, and is simultaneously significantly less likely to receive surgical treatment for obesity compared to higher-income, privately-insured, White patients. 2 The ability to reach out to this vulnerable and underserved population while in a controlled and healthcare-supported environment might provide a unique opportunity for positive intervention with potential lifelong health benefits. 7 What's more, since bariatric surgery is known to be the most effective treatment for obesity, principles of justice and equity would demand that incarcerated patients with obesity have equal access to optimal treatment of their chronic disease. Unfortunately, the incarcerated population is also likely to suffer worsened health outcomes upon release from prison, including fewer with a primary care physician and more with preventable hospitalizations. A strong relationship with a bariatric surgery program, and its oversight of long-term follow-up, might offset this to some degree, although high rates of non-insurance or under-insurance on release might complicate subsequent access. Despite the promise of this proposal and the above arguments in favor of bariatric surgery in the prison population, there are numerous concerns, obstacles, and counterarguments that must be considered. These can be roughly broken down into medical and non-medical. The nonmedical arguments against this proposal center around the legal, moral/ethical, and political obstacles that wound have to be overcome. The courts have clearly upheld the right of prisoners to "reasonably adequate" medical care under the Eight Amendment to the Constitution, but there is no universal right to non-urgent or elective surgery. 8 Although bariatric surgery is widely recognized as the gold standard for patients with obesity and metabolic disease, it would still fall under the category of "elective" as defined by insurers and the prison medical systems. Despite the authors' arguments that prisoners should have the same access and options as non-prisoners, J o u r n a l P r e -p r o o f there clearly is legal, moral, and ethical precedent that many rights are altered or forfeited during incarceration. 8 These include freedom of travel, association, voting, employment, holding office, etc. There is also significant precedent in restricting access to bariatric surgery among certain populations due to situations factors and potential adverse impacts on the individual and affiliated group. For example, active duty U.S. military service members are currently barred from undergoing bariatric surgery even if they clearly meet qualifications, due to the perceived impact on their readiness and deployability which could adversely affect the system. These same arguments can certainly be made and readily justified for the prison population. In addition, one could readily see the moral, political, and social justice issues in a situation where a prisoner convicted of murder is able to receive taxpayer-funded bariatric surgery, while equally qualified family members of the victim are unable to afford the same opportunity due to insurance and access reasons. Unfortunately, the solution to many of these equity and justice issues related to medicine and surgery, namely universal single-payor healthcare coverage, continues to be an uphill political battle. Of equal concern and controversy are the numerous medical and healthcare minefields that would have to be successfully navigated to ensure acceptable preparation for surgery, performance of the procedure, and short and long-term postoperative care. Although the prison population may seem ideal for bariatric surgical intervention due to the high prevalence of obesity and obesity-related disease, it is also a population with a much higher prevalence of negative factors such as major psychiatric illness, behavioral disorders, drug and alcohol abuse, low health literacy, and non-compliance. 5, 6 Thus any program would have to have an extremely careful preoperative evaluation process and maintain highly selective criteria, or alternatively be exposed to a higher rate of postoperative complications and failure rates similar to what was seen J o u r n a l P r e -p r o o f with the Medicare patient population. 9 Additional concerns regarding the role of the autonomy of prisoners to give informed consent and the impact of coercion or secondary gain on their decision for bariatric surgery require careful consideration. Although the authors argue that the preoperative and postoperative nutritional evaluation, counseling, and management could be handled by the prison system and their available pool of dieticians, we feel that this is unproven and highly suspect given our own encounters with numerous prison medical systems. In an analysis by the Marshall Project (www.themarshallproject.org/), numerous and widespread instances of inadequate nutritional programs were identified. This included reports of inmates "eating toothpaste and toilet paper" to supplement what was described as "starvation rations". Multiple other series have demonstrated huge disparities in nutritional delivery throughout our nation's patchwork system of federal, state, local, and private prisons and jails. U.S. prisoners are six times more likely to get foodborne illnesses and have filed numerous lawsuits related to substandard nutritional programs. Most correctional facilities now utilize outside contractors who deliver pre-packaged meals rather than in-house kitchens. These meals have been largely found to be high in sodium and carbohydrates, and with less options for variation in content and amounts to meet the needs of prisoners with specific dietary needs or restrictions. In addition to being a major obstacle that would have to be addressed before initiating a prisoner bariatric surgery program on any kind of scale, the optimizing of prison nutrition may be a potentially high-yield target for improving health and outcomes and even avoiding the need for bariatric surgery in select populations. Finally, the critical issues of postoperative care, close medical/nutritional monitoring, and follow-up has been only superficially addressed in this piece. One only needs to perform a brief internet search to identify numerous stories and investigations of a prison medical system that is J o u r n a l P r e -p r o o f understaffed, undertrained, and overwhelmed with just meeting the day to day routine and urgent healthcare needs of the prison population. Thus, the postoperative care and monitoring would need to either be done in the prison setting by existing personnel, by hiring new prison personnel, or by frequent transport of the patient to the hospital or clinic and any other ancillary visits that are required. This again would require significant infrastructure, coordination, training, and of course adequate funding and monitoring to ensure even a bare minimum level of success. For these reasons we also remain somewhat skeptical about the prediction that such a program would be cost-neutral or even cost-effective. The existing data on the overall cost effectiveness of bariatric surgery in non-prison populations is contradictory, highly dependent on the patient population, and at a minimum becomes cost-neutral or negative only after a number of years. There is significant evidence to suspect that these same cost savings may not be seen in this population or may be entirely overshadowed by the increased administrative and logistical requirements that such a program would entail. We congratulate the authors for writing this timely, topical, and controversial piece advocating for improved bariatric surgical access in a highly specialized and vulnerable population. Given the numerous complex considerations, logistics, and potential second and third order effects of such a program, the question remains regarding the best way to proceed. We agree with the authors that this proposal certainly has merit and is worth pursuing, with the caveat that careful attention is paid to all of the concerns raised above. A small and focused pilot study at a location where the bariatric program is able to partner with a willing prison medical and administrative team would be the ideal start, and could provide critical experiences and data to guide future similar efforts or program expansion. J o u r n a l P r e -p r o o f Socioeconomic and Racial Disparities in Bariatric Surgery Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis Racial disparities in mortality in patients undergoing bariatric surgery in the U Should Bariatric Surgery be Offered to Prisoners? Medical Problems of State and Federal Prisoners and Jail Inmates Mass incarceration, public health, and widening inequality in the USA Bariatric surgery among vulnerable populations The authors have no financial dislosures or relevant conflicts of interest related to this workThe opinions presented in this work are solely those of the authors, and do not represent the opinions or policy of Jacobi Medical Center, Albert Einstein College of Medicine, Scripps Mercy Hospital, or any affiliated organizations.