Extreme Weight Loss. Amber Wutich
was also helpful that all three of us had our own extensive prior ethnographic experiences, each having conducted long-term field projects in very different places. We had all experienced field research gone wrong, where community relationships were compromised by misunderstandings or miscommunications. We had implemented multiple ethnographic methods many times previously. As a result, we were not learning how to implement various parts of a collaborative, multiyear project on the fly as we rolled the project out. Working in a high-profile, highly regulated clinic means there is not a lot of room for error or do-overs: a serious error and we would have lost access to patients and staff. We have provided details of the methods we deployed in this study in the appendices, for those who are interested in how we went about data collection.
Our particular three-person ethnography in a clinic produced two major interpretive limitations, however. The first has to do with us as individuals. One of the major critiques of social science studies of stigma is that many studies are conducted by people who do not have insider status with the group being studied; in other words, they do not share the vulnerable trait. In this case, none of us have personally experienced extreme obesity or gone through bariatric surgery. Our perspectives are built on multiple years of carefully listening to people who have experienced both of these embodied states, but we have not lived/embodied them ourselves. Sometimes—given rampant fat stigma across many sectors in the United States—this has proven to be an advantage in our work. In certain settings, we are perhaps given more credence than we would be if we were read as fat people (just think of the uphill battle obese physicians face with regard to respect from patients and other providers). At the same time, however, our “outsider status” almost certainly affects what people do and do not feel comfortable sharing with us. Our findings should be tempered with this understanding.
The other interpretative limitation stems from the particular nature of our relationship with the clinic. As was hopefully obvious in our earlier descriptions of our relationship building within the clinic, in order to conduct research within this space, we had to adhere strictly and revert consistently to the authority of clinic rules and norms. There was little space for negotiation over the form of the social science research in which we were involved, compared to what we have previously experienced working within nonclinical settings. Our human-subjects research application (which any US-based researcher who wants to conduct research on humans must submit in order to be in compliance with current international ethical standards) went through the clinic’s review process first, before our own institution would even review it. This oversight was ethically and pragmatically necessary, but it did impose certain restrictions on the degree to which we could ask critical questions within clinical spaces. For example, once question sets for interviews were approved administratively, we could not then follow emergent ideas in new directions to the extent we are able to do on other ethnographic projects. Similarly, basing ourselves in a clinic meant that some of the boundaries of the clinic-patient relationship also applied to us. If a patient dropped out of the clinical program, for example, we tended to lose sight of them as well. This was particularly frustrating in some cases but does help to explain why data on the postoperative lives and health of bariatric patients in the long term, more than five years after surgery, is lacking more generally (although there are exceptions).21
Finally, we feel it is important to note that as ethnographers, our overriding ethical commitment in any project we undertake, whether individually or as a team, is to depict the cultural worlds of our participants in a way that does them no harm. Because they were bariatric patients, most of our participants had suffered a great deal of stigma and social devaluation, and we therefore felt this duty especially strongly on this project. Although we are well aware that other theoretical lenses, including a critical lens, could be applied to our research, we have opted not to do so ourselves. Instead, we provide enough ethnographic depth and rich description to support alternative readings and leave such analyses in the hands of the reader.
Organization of the Book
The anthropological ethnographic tradition once idealized the notion of a single researcher heroically collecting data (often while awkwardly appropriating “native” dress), analyzing it, and then going home to write it up in his study (and yes, it was usually “his”). The reality is that this research approach could never handle all the complex realities posed by on-the-ground, in-depth research. The ideal still retains great power, but we have found working as a collaborative unit on this project allowed us to comprehensively approach many methodological, theoretical, and practical challenges. Writing about our research as a collaborative unit has been more difficult. For one thing, first-person narration dominates much of the current compelling ethnographic writing. Most of the ethnographies written recently, for example, are framed firmly in the first person with careful attention to what the writer did, said, and saw—and how their own experienced self influenced what they did, said, and saw. This avoids the problematic third-person omnipotent narrator perspective, but it puts multiple authors, who necessarily were in different places at different times performing different tasks, in a bit of a bind.
After a great deal of internal debate and some external consultation, we decided to rely mostly on the use of “we” and “our” in the introduction and conclusion, which give more of an overview and a theoretical framing for the chapters that form the rest of the book. When necessary, we refer to ourselves in the third person by name. In the remaining chapters, the content- and participant-driven chapters that give primacy of place to participant-patient narratives and experiences, we again write mostly from a “we” perspective, but we more frequently refer to ourselves in the third person (again by name) because there are more instances within the fieldwork in which only one or two of us were present at any given time. Sarah, for example, conducted the interviews that form the core of the ethnographic research described in these chapters. Alex shouldered the task of managing the potentially fragile relations with hospital administrators. Amber devoted substantial time and effort to working out the methodological ramifications of different aspects of what was an extremely complex ethnographic project in an ethically sensitive context. We thus attempt to capture all of these individual experiences within our three-person team via a thoughtful, patchwork use of first-person-plural and third-person-plural perspective. In this book, no one wrote sections for which they themselves were not present. The shifting voice, however, hopefully highlights the fact that our points of view are just that. We do not and cannot know all that occurred in any given situation.
In Steering the Craft: A 21st-Century Guide to Sailing the Sea of Story, Ursula K. Le Guin writes about first-person narration, saying, “In nonfiction narrative of any kind . . . the I . . . is the author. In these forms, we normally expect the author/narrator to be reliable: to try honestly to tell us what they think happened. . . . The memoirists and nonfiction writers I respect are fully aware of the impossibility of being perfectly factual.”22 We strive to be reliable, even as we wrestle with our limitations, and to give due respect and attention to those ideas and experiences that our participants most wanted communicated to a broader audience.
In our writing, we also decided to organize the book around four key themes that emerged over and over again in our analyses: (1) weight as pathology, (2) weight as judgment, (3) weight loss as success, and (4) weight, worry, and perpetual surveillance. These themes are discussed in a semilinear fashion that roughly tracks the before, during, and after phases of the patients’ surgical journeys. Each chapter explores a different way in which the “burden” of weight is experienced in individual lives, acting as a prism for broader social processes. These are themes we see as important not just for anthropological discussions but also for clinicians and the general public.
In chapter 1, “Weight as Pathology,” we focus on the ways in which weight becomes a problem for people because it is framed as a medical issue. By this, we mean that obesity in medical terms is considered a disease and public health concern. In chapter 2, “Weight as Judgment,” we discuss how and why weight is a problem based on the fact that it has become a signpost and signal of a lack of individual moral worth and social standing. In contrast, in chapter 3, “Weight Loss as Success,” we show how lack of weight and/or weight loss signals worth and greater social integration. Finally, in chapter 4, “Weight, Worry, and Surveillance,” we focus on the ways in which weight maintenance,