Saturday, 25 February 2012

Fat future

Why are we even talking about this? The Government thinks it's a great idea and an 'innovation' to make special ambulances and resources available for drunk people. Getting specialist ambulances in for the grossly obese should be no biggie.

I've noticed the rise in larger patients among the elderly and this is quite shocking, because it indicates a generation of obesity that is about to slam into our NHS budget, causing a crisis like no other. It is already a fairly regular occurrence for crews to call in and request a bariatric vehicle for a patient they simply cannot carry, even on the newest ambulances with the wider beds. Private ambulance companies, like the one shown, are investing millions because they can see the future.... and the future is FAT.

The whole concept of spending millions of public pounds at a time when we are all being told to 'tighten our belts', is laughable and crudely paradoxical. I know that many obese patients got where they are because it is not as simple as not eating as much, but it is still due to excess that most of them are in that position. why are we paying for it? Why, in fact, are we paying to help out drunkards by giving them special vehicles and facilities too?

The bottom line is this: we haven't got the money for this nonsense. It would be cheaper to have everyone with a serious weight problem banded without fee if they reach a certain weight. Many obese people want this done because it can save their lives. However, it costs the NHS and there is a bit of moaning about that. How ironic then that we send that money (the same money that would be spent on banding) into the private sector so they can be trundled to and from hospital many times before they succumb to their disease.

I can see another future. Those binge-drinking kids that think it's so cool. A proportion of them (not all of them) will continue to drink like that and they will become alcoholics. We will see that generation filter into the NHS purse as a direct result of their ignorance within the next decade or so. Check back here in 2022 and see if I'm wrong.

Oh, and I'm not having a go at the obese; I'm having a go at our complacency to deal head-on with our problems. It's ridiculous. There are plenty of people out there who were once obese but got their act together and stopped bemoaning their condition as if it was someone else's fault. They lost weight and saved themselves. Even those who elected to get a gastric band fixed have acted to stop the rot.

So, instead of supplying indefinite funding, why don't we just educate people properly? Spend the money teaching people how to eat and drink wisely. Poor old Jamie Oliver tried to do this and got slated in the USA because they didn't like being told what to do! I expect my views on this subject will get me a similar reaction from some of you. That's a shame because I'm simply saying what everyone else is thinking.



Anonymous said...

People can think (and say) whatever they like. I had a number of people tell me that some variation on "you just need to get your act together" or offer me (unsolicited and sometimes dangerous or absurd) advice on how to lose weight. That was a bit annoying. Who does like being told what to do, especially when the people doing the telling have plenty of problems of their own? However, what was more annoying was being subjected to other peoples opinions without ever being offered any substantive help. I've yet to meet a person who not only wants to inform me that I'm fat, but is also offering me cooking lessons, money for groceries (or a better-paying job that would allow me to buy better food), free medical treatment or membership in any of the reputable plans, a gym membership, or anything like that. After I asked them, my parents (who do bear some responsibility for my "weighty" problem, which existed long before I had the intelligence, knowledge, or independence to do anything about it) have helped with a few of those things. I've still done most of it on my own. And nothing made any lasting difference until I finally found a competent doctor who managed to determine the major underlying cause of my obesity and some other issues. (I sought and am paying for treatment myself, too.) Weight loss wasn't even a realistic possibility before the treatment. My "issue" isn't visible, so a lot of people thought I was just a fat, lazy fuck, despite the fact that just staying afloat was a near-constant struggle for me and that people who do know me have long commented on my determination and work ethic. Knowledge is important, and it's taken me a long time to gain. It's also important to have the tools to effectively make use of that knowledge, and it's tremendously helpful to have a supportive environment that favors patience and empathy above judgement.

What are you doing, Stu? Are you teaching people how to cook? Storming Parliament with demands for further restrictions on processed foods? Leading a walking club for the middle-aged farts of London? Helping individuals who are struggling with their weight to find appropriate plans or (in some cases) medical treatments? Helping find treatment for people whose weight problems, as serious as they may be, take a backseat to more pressing medical, mental, or emotional issues in their lives? Going around and defending the awkward fat kids who find that it's easier and, temporarily at least, more enjoyable to stay in and watch telly and eat junk than it is to be outside getting picked on by those who are bigger, stronger, and more popular? Do you offer support and guidance to people you know who are trying to lose weight, without also judging them for their failures and their difficulties?

Or are you another person who just likes spouting opinions about what "the government" should do or how other people need just need to try harder to fix what you deem to be their most pressing problems?

Xf said...


Please go back and read very carefully what I have written. I am exposing the stupidity of throwing good money after a bad problem without thought of dealing with the issue head-on. I have not demonised obese people, nor made any comment that suggests they all do nothing about their situation. Do you not think for one minute that I might be commenting from not only a professional perspective, but a personal one, and that I might have friends and family members with similar issues?

Do you not think I might have studied this subject in some depth and actually have a very wide knowledge of the problems and societal issues surrounding obesity?

Is it not fair for me to consider the physical damage that is being caused to healthcare professionals (that's mainly us incidentally), who have to lift and carry ever-increasing weights, sometimes whilst trying to save the life of a person underneath that weight?

Did it cross your mind that I might have these opinions because I actually care?

Every time I publish here, I take calculated risk. I risk the backlash of many thousands of people who may not agree with me. I would still say what I have said, even if I was surrounded by these people.

Everyone has problems and everyone has to deal with them in their own way, I totally agree. But not at the cost of everyone else.

Strangely, I haven't yet heard from a binge-drinker defending their problems.

Anonymous said...

I've been a reader of this blog for a while and I can only agree with the article.
I am one of those once obese persons. At one point, I went for my usual contraception jab and the nurse asked me whether I ever wanted to have children. When I confirmed she told me "Well you better loose some weight then 'cause a) you might not get pregnant or b) if you do it'll be dangerous for you and your child might suffer from obesety later on. That was my wake up call, so I asked my GP for help. And I got it. He sent me to see a nutritionist, told me to start doing sports by joining the local community centre's aqua class and prescribed me Orlistant as a means of controlling how fat the food I eat is. It has worked. My surgery's strict supervision along with determination on my side has changed my life. I will be running my first half-marathon in a bit. Botton line for me is: Tackle the problem, not the result. The problem is obesity, the result is larger ambulances etc. There are so many possibilities for obese people to get help. They have to want to get help. We should not support people being obese, it's not normal to be fat. Obese people should be discouraged to pile on further pounds and encouraged to become fit and healthy again.
And for god's sake, stop feeding all those morbidly obese people who are bed-ridden.

CFR1972 said...

As a society, we do seem to be throwing money at end results of problems, rather than at the initial causes. WE'd be in a sad state of affairs if doctors only treated symptoms and not diseases. I agree with you.

Anonymous said...

I agree with much of this post and, as a fatty, I live in dread of a medical emergency or just a sprained ankle that would mean other people had to try and help move my mass around. I DO care, a lot, about these things.

However, the suggestion that education and gastric bands would 'fix' the problem in all cases is pretty naive and simplistic.

I am obese, yes. I also have a PhD, I have read widely on the subject, I know how to cook healthily and well and I can afford the ingredients for a healthy diet. So why don't I stick to it and lose weight? Because I also have mental health problems, and when they're bad I lose all will to do anything else, and I eat rubbish and sleep and that's pretty much it. I'm capable of acting functional and holding down a job, so the NHS can apparently only provide me with medication (no psychiatrist appointment etc., just the best my GP can manage) and the odd 6 sessions of CBT, which is sufficient to enable me to carry on working but not to deal with the wretched eating symptom - and it is a _symptom_. I don't eat because of hunger, I eat because of depression, anxiety etc. I eat when I already feel sick from overeating, it's NOT ABOUT HUNGER. I hate my body, I hate being like this, I try every day not to be like this, and I fail.

From my reading, I understand that gastric band surgery is usually done only once the patient demonstrates the ability to have some discipline around food, as bingeing with a band in can have serious medical consequences. Am I wrong? I envy anorexics. No-one tells them that they're a huge cost to society etc., and people care. Us fatties - it's all our fault and we're a drain on society and we just need to stop being so stupid and selfish, right? No, I have an eating disorder as well.

I know what to do and I can't do it often enough to get out of this trap, and that's not out of stupidity or selfishness. I need help with the underlying cause, and it isn't there because I'm 'functional', not ill enough - and given how stretched and beleaguered the NHS is, I do understand that. But saying I should just get a gastric band fitted is not going to help - dealing with the consequences when I screw that up too next time I have a bad patch would cost the NHS as well.

I appreciate your point, and you're probably right, but just as saying 'don't drink' isn't going to help tackle the causes and prevalance of alcoholism so 'get a band' isn't a panacea for addressing weight issues.

Anonymous said...

I hate the fact I am overweight, but in truth I do not think about the added expense I might cost the NHS. Although (and this may sound stupid) part of my thoughts when I want to kill myself is I can’t do that, the ambulance crew will not be able to move me if they get called (see us fat people can be thoughtful!).

one brave duck said...

i feel in a bit of a catch 22. i was prescribed a pretty powerful anti-psychotic to help with my bipolar, and weight gain was a known side effect. in fact, this drug is notorious for it. after six months, and a massive weight gain, they switched me to an alternative. i've tried just about everything and haven't been able to shift back to the weight i was at before psych drugs. i'm currently on a cocktail of 4...

the catch 22 part is that i believe these drugs not only kept me out of the hospital (i was in and out before medication), but probably kept me alive. my depressions were so severe suicide was a serious threat.

so here i am, out of the hospital, doing well on the mental health front, but without a doubt, fat. i know i need the meds, i just wish they had fewer side effects.

i don't know what the answer is... but thank you for letting me share part of my story.

Anonymous said...

I enjoy your blog and have done for a long time.Sometimes I wonder if another job would suit you better for you seem to find so much annoying.
I understand a lot makes you angry but sometimes I think you may have burn out perhaps. Then you mention private companies and profits almost as an afterthought so the personalisation of your patients doesn't look so bad.Seeing so many as selfish people, a sap on society who should sort themselves out.
Most binge drinkers grow out of it. The problem is deep routed. I have children/mini adults, 21 and 19. The eldest a girl, finds that often girls are allowed in free, given free alchohol especially shots. This is a big problem. The boy 19, says there is a culture that it is manly somehow to drink and drink especially shots after pints. Peer pressure does occur. I feel it is my responsibility as a parent to educate my children with regard to alchohol abuse and how to go out without making a complete arse of oneself, ending up in hospital, or worse. I know it is a big problem and that many feel education is the key and that enormous funds should be put into this. I worry that this is necessary yet I know that it is naive to think that the family values that I try to instil in my offspring are happening all around the country. I talked and still do to mine about self respect and I am not pious or over strict. To an extent I blame a system that has allowed large venues to sell at low prices, when I was young, a pint of beer was still cheap and spirits expensive, a luxury indeed, perhaps respected. Now it seems spirits are considered something that one chucks down the throat as if it were orange squash. I feel it would help to deal with the problem because it is a big one, if the large venues responsible for pouring out drunken, violent and sometimes dangerously sick people had to have room in their premises for treatment of these people. Where they took the responsibility out of their fat profits for the carnage they cause. I think perhaps that is just dreamland stuff though. I do feel sorry for you when you have to deal with the binge drinkers when you signed up to deal with the sick. But sometimes I wonder how you deal with those who need your attention, it sounds as though you are cold hearted although I am sure you are professional. Yet I understand your frustration.
Its all complicated but unravelling it all and entering the blame game will upset and naturally enrage.

I wonder if there is any condition that you think is not the patients fault. A few maybe. I think you may think that I shouldn't have had children as I have a genetic condition, considering me also a sap on society. I wonder if there is anyone that you don't think is.

I don't actually think we are breeding a nation of alcoholics most grow up, have families and just worry about the bills. I think there is too much emphasis on legislation and prohibition, proven not to work. I don't have answers I wouldn't be so bold. I do think your work is stressful and its hardened you. I think the majority of binge drinkers feel remorse at some point, but not when you see them that much is evident. Perhaps you expect too much.
On the obesity front, I applaud your annonymous commenter for saying what he/she said. I think it was a little churlish of you to pull the comment apart, just saying. That comment came from the heart and I think it would have been better had you left the comment to stand on its own merits. I didn't think there was any element whatsoever of personal critism to you in it, just one persons story of their journey.

It would be good to hear you speak of a good day.

Xf said...


The opening lines of your comment are personal, don't you think? Opinionated. You don't know me but I do not protect myself with 'anonymous' when I speak out. Neither have I singled out anyone with personal rhetoric.

My statements are based on facts that are killing society and yet, I am still hearing this from people. I am still hearing that it is the way I see things and not the way they are. How strange, as we are currently in the middle of a crisis with both alcoholism AND obesity in this country.

I applaud your family values and I fully support the way you are tackling issues within your own circle. You do not, however, do my job, and you therefore do not have any idea of what I do or do not experience.

I am not 'burnt out', although I'm sure I've sailed close to it and I am not 'cold hearted'; it was rather cruel of you to suggest that.

There are plenty of good days in my profession but I am speaking out about problems that are not being dealt with precisely because a few will stand up and complain that it is an attack on them somehow.

I don't know you but please do not presume that I care nothing of others. Whilst I write this, another obese or stupidly drunken person will be taking an ambulance away from an old person or a child who is in trouble and who needs our help because they are unwell or injured through no deliberate fault of their own. They did NOT continue to drink or eat in the face of their ever-deteriorating health when there was an option for them to just slow down, stop or seek help.

Whatever your genetic condition, how would you possibly know whether or not I also have problems that I deal with every day?

But deal with them I do. I do not burden the state and cost the taxpayer with self-inflicted issues, whatever the emotional or psychological reason.

And yes, I did say that not ALL obese people can do something about it. There are conditions that predispose weight-gain.

I agree with your comments about the drink companies taking responsibility but only to an extent. Parents have the ultimate responsibility. When youngsters on TV are filmed proudly proclaiming that they live in 'binge Britain' and are stone cold sober when they say it, maybe it's time to consider the future.

And my last anonymous commenter's statements were not trashed by me you know, I debated them. If you read the comment, you will have noticed that even s/he blamed someone else... an influence that s/he could not have avoided - parents.

Xf said...

One brave duck

Thank you for giving this debate a bit of perspective. Drugs, alcohol and smoking can all cause weight gain as a side-effect. Smokers who stop, for example, are known to pile on the weight and often go back to smoking in order to stop the rot.

Some prescription drugs, such as the ones you were given, will also have that side-effect and, of course, drinking too much on a regular basis will add mass.

A balance of exercise and diet will help with this but your GP will advise you on who to see about getting things under control. Remember, fat is stored energy. Burn it off and try not to add to it and you'll get yourself back to where you were. Hopefully, the drugs haven't messed up your metabolism too much.

Xf said...

Anonymous (PhD)

I think I made it clear from the outset that I appreciated not ALL obesity was the result of selfish over-eating. Gastric banding is only given to those who will abide by it's 'code' and if they don't there are severe consequences.

But please do not continue to consider what I say as a personal attack on people, when I am trying to focus on a serious problem... not just in this country but elsewhere.

I agree totally with you that MH issues are entwined with weight gain and the lack of desire to do anything because depression, which I have experienced at a much milder level than yourself, causes life's brakes to engage.

However, you are intelligent enough NOT to be telling me that we should equate obesity with Anorexia?! Are you saying that in the USA, for example, there are entire States where Anorexic people walk around in the majority?

Are you telling me that the majority of obese people are suffering MH problems?

Or is it not, as I have tried to say here in this post, the result of lifestyle choices, poverty and a generally ignorant status?

If I was the one paying singularly for the NHS, I would be doubly peeved about this. But I'm not. We ALL are. You contribute to the cost while struggling (possibly) just to keep your own head above water.

This post was about the cost to all of us and the personal health cost to those for whom binge eating and binge drinking have simply become their choice, regardless of anyone else.

Oh, as you are an academic, did you know that a recent scientific study has suggested that we will run out of land for growing food as the population increases. The larger among us will devour most of it and the lesser of us will suffer? It's all a bit 'panic-button' isn't it? But we've done it in the oceans and elsewhere.

Xf said...

Anonymous (ex-obese)

Thank you. I think I need a bit of support here from those who've 'been there and done it'.

Good point though. Being obese is NOT natural. I would have said it myself but I probably would have had a hit man after me!

The body is designed to store fat so that, in times of scarcity, we can survive long periods without food. Most other animals use this system to stay alive during drought, etc.

However, we have developed into creatures with Asda and Tesco on the doorstep. And now, of course, as a contributory factor, these giants have introduced the ability to do all your shopping online, so you don't even have to walk from your car to the shop itself.

When I was growing up, you had to walk from one shop to the other to get what you wanted. There was no Sainsbury's superstore. So, in the course of shopping, you actually lost a bit of weight and stayed fit.

Other animals have to walk for miles, or tens of miles, just to get food for the day. We do not.

I was attacking the lack of head-on honesty with this issue. I was NOT attacking individuals. Like you, I was speaking of the problem and how we are ignoring it because we do not want to seem 'insensitive'. Yet, an honest in-you-face nurse probably saved your life.

You could have told her to sod off and mind her own business. You could have spouted stuff about living your life your way, etc. But you didn't. You listened to someone who cared about you and your future baby because she has seen the terrible consequences.

Good luck to you :-)

Anonymous said...

I wanted to add another comment to the person who mentioned medication and weight gain and how I agree with what you said. I successfully lost five stone through diet and exercise and felt great about myself and my future, that was until my psychiatrist commenced me on Quetiapine and I gained five stone back in about six months... I stopped the drug at the end of December 2010 and I am still struggling to shift the weight I gained back. You only have to take a look around a psychiatric ward and you can hazard a guess who is on mood stabilisers or anti-psychotics because the majority of them continually eat, and drink sugary drinks because of the thirst issue and they are overweight, but given a choice meds or jumping off a tall building which would you take...

It would be more beneficial to give WLS to those over a certain weight, those who have Binge Eating Disorder that treat them on the NHS for the next 50 years of their life, but the NHS unfortunately cannot see this. Surely giving someone WLS, support via psychology and follow up with a dietician or weight management team is better than them needed help 30 years down the line, in the USA they give WLS to people with insurance in order to avoid it costing them more down the line!

I am currently under the Weight Management Clinic and personally it is a joke, the support is rendered useless because they are telling me nothing I do not already know, and even worse it comes from a Consultant who is more obese than me (go figure than one out!).

Anonymous said...

I wanted to add another comment to the person who mentioned medication and weight gain and how I agree with what you said. I successfully lost five stone through diet and exercise and felt great about myself and my future, that was until my psychiatrist commenced me on Quetiapine and I gained five stone back in about six months... I stopped the drug at the end of December 2010 and I am still struggling to shift the weight I gained back. You only have to take a look around a psychiatric ward and you can hazard a guess who is on mood stabilisers or anti-psychotics because the majority of them continually eat, and drink sugary drinks because of the thirst issue and they are overweight, but given a choice meds or jumping off a tall building which would you take...

It would be more beneficial to give WLS to those over a certain weight, those who have Binge Eating Disorder that treat them on the NHS for the next 50 years of their life, but the NHS unfortunately cannot see this. Surely giving someone WLS, support via psychology and follow up with a dietician or weight management team is better than them needed help 30 years down the line, in the USA they give WLS to people with insurance in order to avoid it costing them more down the line!

I am currently under the Weight Management Clinic and personally it is a joke, the support is rendered useless because they are telling me nothing I do not already know, and even worse it comes from a Consultant who is more obese than me (go figure than one out!).

Amanda said...

MsLeftie has just hit on a point I was going to make. I am a great beleiver in leading by example - but has anyone else noticed how many doctors, nurses, other hosptal staff and even paramedics are overweight/obese? I think they have a duty to "practice what they preach" so to speak. It's true to say people make assumptions about you from your weight and the way you look without knowing the full story - perhaps all these professionals have mental health issues, take drugs for medical conditions etc. I think the majority of people recognise the problems we have in society such as binge drinking and obesity but we just don't have the answers in overcoming these problems.

XF - I have been a fan for a while now and have often written a comment but not ended up posting it! I think its great in this all too PC society for someone to stand up and say not only what they think but what they actually know is to be true through the type of work they do and to encourage debate about such issues. Keep up the good work, I for one appreciate it, thank you!

Xf said...


Thank you. I knew this post would stir up a hornet's nest; I am expecting the Press to publish something from this soon, probably saying I am a fatty-hater or something!

And you are right. Individuals in the healthcare profession should not be obese. It gives it a terrible image. You simply cannot preach good healthy living to patients when you yourself are heading to destruction due to excess. A recent TV programme featuring young, newly-qualified doctors included an obese medic, running around the hospital like a hero, panting and puffing as he did so! It looked very bad in my opinion.

He is, no doubt, academically and medically able to do his job but if he doesn't lose weight, he will not be fit for practice.

The same is true in pre-hospital care. Overweight and obese paramedics need to consider how they look to patients.

Nurse and Hospital Stories said...

I agree. Though the fact remains that obesity is the number one health issue today of Americans especially the teenagers. Indeed it is a very fat future for us. :(

Thanks for the share,
Peny@scrubs free shipping

Anonymous said...

Great work with this block I have to take my hat off to you, for having the bravery to actually make your opinion heard in public. I am also a member of the LAS and the fact that you made your name public is actually very brave. I will agree with you on the binge drinking culture bit. Working in the control room on a Saturday night makes you realize how deep the problem is. When you have a stroke patient waiting for hours sometimes because there are a lot of "unconscious " people lying outside bars and clubs. Makes one think if there is something that should be done urgently to educate the public. Again well done and keep up the good work

Anonymous said...

Part of the reason I withdrew from starting Mental Health Nursing days before I was due to start was because despite losing weight I was still obese, and I hated the fact I felt I was unfit to work in a nursing environment.

Caroline84 said...

Hi Stuart,

Upon reading your latest post and the comments made, I personally think that you are in a no win situation with regards to your blog in general. If your blog contained emotional posts, people would say that you are too emotionally fragile for your profession.

Because you document your day to day work in a honest way without involving too much emotion, you are accused of being judgemental and cold hearted.

Medical professionals are constantly under scrutiny for not behaving in a way that pleases everyone. I think it's time we all took a step back and considered that delivering care and medical assistance to other humans is a tough job on its own, without the strict targets, physical and verbal abuse and constant pressure to live up to other peoples' expectations.

On the obesity subject, I think that health ministers should be looking into the reasons behind the condition, and then helping those with weight issues to overcome them.

Xf said...


Precisely my point, thank you. I think we need to tackle the problem in an open and absolutely honest, even-if-it-hurts-your-feelings, way, otherwise people are going to die, en-masse, due to excess.

People will also die needlessly because there were no medics there to help them because they were too busy dealing with self-inflicted illness.

If anyone is still willing to make this a personal thing with me, maybe watching 'Supersize vs Superskinny' on TV might help them understand my point.

Anonymous said...

As a resident of the US, where elderly and disabled are losing benefits because of "overall costs of healthcare" which includes a significant amount of care for voluntarily obese, I am glad that someone in the healthcare field is willing to speak up. For those who are obese and cannot help it, that is a separate issue. To speak to the problem is not a sign of not having compassion. Sometimes being compassionate means having the guts to say what isn't popular. When I was training as a therapist, trainees were hesitant to ask clients if they were suicidal or thinking about killing themselves for fear of hurting their feelings, yet not asking could mean missing a key sign and end in a completed suicide. Sometimes doing the right thing means asking difficult questions.
For some people being thin is "easier" but just because something is hard doesn't mean that a person shouldn't do it. I watched one of my loved ones lose a significant amount of weight and keep it off with diet and exercise. I am thin, and I see a distinct difference in the choices that I and thin friends make and the choices that heavier and obese friends make. With the consequences of being obese, both to the individual and society, we have to start talking openly about the subject.

XX said...

I would also just like to say well done on not being too afraid to vocalise what I think is quite a valid opinion.
Likewise to everyone else who has posted their equally valid opinions, as there is always more than one side to something.
As for Paramedics and Doctors etc being fat - ABSOLUTELY! And often that just comes down to lack of respionsibility. The job we do can be quite demanding, and having to grab food on the go as and when you can (or risk going hungry) means its likely fast food will be the most convenient! I have done this so so many times! I am not over weight but I see how easy it would be to become overweight, there are not enough hours in the day to do everything right every time!
While I appreciate fully that there are so many things that can cause obesity dispite someones best effort to prevent it, it is also clear that in the remaining cases, there is just a complete lack of responsibility.

To the person who commented asking who is offering to pay for gym memberships, more money for healthier food etc... you are right. No one is standing up and offering to help in this way. In a small number of ways I think this is a shame because this would be a great way to tackle obesity. Head on.
But overall, not only would that be costly, but extremely unfair. Why should somebody who is obese be given extra benefits, whether their obesity was their fault or not?
Gym mmberships for one are extortionate! Any healthy individual would benefit from one to help reduce the likelihood of CVD etc, and it is simply not acceptable to leave out others who could benefit.