Walking the Walk

One of the most important reasons that social scientists are not like, say, physicists or chemists or mathematicians or even biologists, is the reflexive property of what we do. Although it is true that human beings are physical entities, made of chemistry and biology, that doesn't cause a great deal of confusion for scientists because the intellect and philosophy we use to study those elements has the privilege of standing outside of them, or at least pretending to. The personal experiences, cultural background, even the religion of scientists doesn't muck up those endeavors. (Creationists are people whose religion causes them to reject the foundation of biology, but they are not scientists and indeed they have a fundamentally different epistemology.)

But I exist in that lifeworld of illness, I interact with the world of medicine, and I communicate every day with the entities whose intercommunication I study. I'm a part of it with my intellect, my emotions, my experience. However hard I try to step away to that remote, indifferent summit of scientific contemplation, I am only deceiving myself if I believe I am truly there.

My father had a stroke many years ago, and although he partially recovered, he then began a slow slide into progressive dementia. Although his neurologist has told my parents that he has vascular dementia, and does not have Alzheimer's Disease, I'm going to overrule her. If he doesn't have Alzheimer's Disease, I don't see how anybody can tell the difference or what difference it makes. It is also rather strange that this ethical healer has prescribed two drugs for him that are only indicated for Alzheimer's Disease, and have no known benefit in vascular dementia.

What is perhaps most strange of all is that the neurologist, and my father's primary care physician, both encouraged my parents to go ahead with having both of my father's knees replaced, as his mobility was somewhat impaired by osteoarthritis and he was using a stairlift. Having lived through the consequences of that decision, I am now more inclined than ever to question the predisposition of physicians to intervention. They always seem to prefer to do something, damn the torpedoes and full speed ahead. A major focus of this diary has always been that medicine is about tradeoffs, not miracles. Benefits come with costs and risks, often unknown, and risks, by definition, are not predictable. But doctors, as a general rule, don't fully inform people about the costs and risks of intervention, because they believe - probably correctly -- that the way most people evaluate risk will make them less likely to accept intervention than physicians, who are trained to think in so-called "rational" statistical terms.

This posting is just a set-up for a more interesting discussion (I hope), but I'd be interested to hear if it resonates with anyone's experience so far.

The American Century is Still Over

You read it here first, but now the CIA has decided to back me up.

Mapping the Global Future

Warning, it's a PDF, it's 119 pages, and no doubt spy satellites are photographing you right through your building walls as you download it, using classified X-ray vision technology derived from the space aliens at Roswell.

If you prefer, Fred Kaplan in Slate has a summary. Fred Kaplan

Tomorrow morning, Cervantes is off for his own personal medical sociological experience, involving his parents and their extraodinarily archetypal, exemplary, and illustrative issues. I may not check in until Sunday or Monday. Meanwhile, keep those cards and letters coming.

Consumer Driven Health Care and other fantasies

As I first discussed in Frist!, below, our wise leaders want to move ahead with the Ownership Society by getting people off of that socialistic comprehensive health insurance and into medical savings accounts backed up by high deductible, "catastrophic" insurance in case they should be run over by a bus. In that way, they tell us, control over health care will be in the hands of consumers, by which they really mean that we'll be paying for most of it out of our pockets although they don't quite put it that way.

The idea of consumer sovereignty that they're invoking is another one of those profound economic theories that is built on false assumptions. In the fictitious "free market," the buyer is supposed to know everything important about a product (good or service), and competing products offered for sale. Then, the buyer can make a "rational" decision about which product to buy, if any. But what the consumer is buying in the case of medicine is the physician's expertise. People don't decide on their own to take a prescription drug or have surgery, they depend on their doctor to tell them what to do. This means that in medicine, we have provider induced demand -- not like the fictitious free market at all, in which demand is generated entirely by consumers.

People do, most of the time, get themselves to the doctor's office or the ER -- although they may be picked up by an ambulance and taken there unconscious, or even against their will. But the doctors take it from there. They decide that we need, for example, a coronary artery bypass graft (called CABG), which is undoubtedly why the rate at which the CABG procedure is done in a given place depends, not on how many people have heart disease, but on how many heart surgeons there are.

It is true that if people have to pay out of pocket for routine medical visits, they will see the doctor less often. This might save society money in the short run, but if it means people get less preventive care and fail to have conditions diagnosed early, when they are more treatable, it will leave us in worth health and could end up costing more in the end. This isn't just speculation. The Commonwealth Fund released a report yesterday that found that half of patients with high-deductible plans accrued medical debt or had trouble paying bills, and that they tended to underuse appropriate care -- they were more likely not to fill a prescription or to show up for tests. Naturally, lower income people and people with chronic diseases are more likely to be harmed in these ways. (Report available here: Commonwealth Fund

These individuals aren't the only ones harmed. The fictitious free market is also one in which all of the costs and benefits of a transaction are felt by the parties to the transaction. But when people fail to get appropriate medical care, others are harmed as well. Reasons include:

• Infectious diseases: Treating and preventing infectious disease in one person prevents its spread to others.

• Productivity: People who cannot work due to preventable or treatable disease contribute less than they could to the economic support of their families and the net economic production of society. They also cannot contribute as effectively to non-monetized but socially important activities such as child rearing, home making, volunteer work, etc.

• Intangible benefits: People would be troubled or disturbed by large numbers of others with treatable illnesses in their midst, and even more distressed if they included people they knew and cared about.

In other words, medicine is not just a private good, it is also a public good, like park land, national defense (which may be a public bad, nowadays), or law enforcement. It is in fact a mixed good, like education, benefiting both the individual and society. Hence, if we leave it up to the consumer to decide when and what to buy, the public good represented by medicine will be underproduced. Imagine if the "Ownership Society" included the elimination of public education -- the logic is the same.

This is not to say that the share of national income spent on medicine should be higher. On the contrary, other rich countries spend less, but their people are healthier. Yet the share of public spending on medicine in those countries is far higher, even 100%. This means that health care in the U.S. is badly misallocated -- too much is spent on some services, not enough on others. "Consumer driven" health care won't solve that problem -- it will make it worse.

We need universal, comprehensive, single payer national health care. Nothing less will do.

Weird, bizarre, and very, very strange

I.e., "abnormal." I referred in the post on disease and illness to the concept of abnormality. Much of our limited time here on earth is wasted in people talking past each other because the normal/abnormal dichotomy refers to two -- or perhaps three -- quite different categories of meaning.

The first sense of "normal" refers to typicality, being somewhere close (exactly how close is problematic) to the average. When we refer to people being of normal height, or normal IQ, that's essentially what we mean. In these instances, we might want to be abnormal -- to be unusually tall or have an unusually high IQ.

The second sense refers to what is considered good, approved or condoned. To a physician, "normal" weight doesn't mean average or typical weight, because in the U.S., the average person is thought to weigh too much. When a physician makes a judgment that a person is too fat, it based on a belief (quite well supported, in my opinion) that having too much body fat greatly increases the risk of unpleasant consequences, including arthritis, type 2 diabetes, heart disease, and premature death.

Unfortunately, there are other bases for considering a personal characteristic not good or not condoned than simple pragmatic concerns about the possible consequences. These include moral disapproval or social devaluation. People who are "too fat" must endure ridicule, humiliation, moral condemnation as gluttunous or undisciplined. They may suffer professional or social disadvantages. I think that this is why some fat people contest the medical view that obesity is unhealthy. They are conflating that judgment with the social stigma they must endure. If we could effectively separate these two very different kinds of judgments, we could simultaneously campaign against the hurtful, irrational stigmatization of overweight while working to find ways to reduce its incidence and help people to lose weight.

Obesity can be thought of as a kind of psychological disorder, as it is related to behavior, although simple caloric imbalance per se has not been given a psychiatric label. But in the area of psychiatric diagnosis the confusion about the various senses of "abnormal" (or "deviant," a synonym which shares the same multiplicity of meanings) is particularly likely to cause problems.

In the area of sexuality, because there are so many different parameters and also because our knowledge is limited, it is really impossible to define "normal" in terms of what is typical or average. Homosexuality used to be a disease. It is no longer, although it is still undoubtedly somewhat atypical. But while it is not a disease, it is condemned by many people, as we know. A friend of mine has argued that Borderline Personality Disorder (a horribly named condition to which I referred earlier) is comparable to homosexuality in that its labelling as a disease is based on a social construct of what is right or normal. I do not agree with him about that, but he is a very smart guy and the existence of such an intellectually respectable viewpoint does prove that psychiatric labelling is of questionable ontological status. (That's a fancy way of saying that its relationship to reality is contestable.) Antisocial Personality Disorder is a more telling example, because sociopaths aren't necessarily unhappy and don't necessarily think there is anything wrong with themselves or their lives (although the less intelligent and less resourceful ones may spend time in jail). We call them diseased because other people don't like their behavior.

So what is health? What is disease? What is illness? Who decides?

Conscience

It would be a stretch for me to say that this is on topic, but there is a movement to organize bloggers to oppose the confirmation of Alberto Gonzalez as Attorney General, and I feel compelled to act in solidarity.

The Bush Administration has brought disgrace and shame to the United States, in more ways than we can count. But Mr. Gonzalez is a particularly important symbol of the depravity of the gang of murderous thieves who have seized power in this country. Mr. Gonzalez provided a veneer of legal justification for many of the crimes against humanity they have committed. Among other despicable actions in his formal capacity as White House Counsel, Mr. Gonzalez endorsed repudiation of the Geneva Conventions, the torture of prisoners, and the argument that the President of the United States, in his capacity as Commander in Chief, is above all laws and treaties.

Now Mr. Bush has nominated Gonzalez to be the nation's chief law enforcement officer. Before the Senate Judiciary Committee, in his confirmation hearings, Gonzalez repeatedly failed to answer questions, continued to maintain that the torture of people designated by the President as "enemy combatants" is legal, and he lied under oath. All of the Democrats on the Committee have now voted against his confirmation, but the Republicans, in a disgraceful betrayal of their country, voted to send his nomination to the Senate floor. Are there enough people of honor in the United States Senate to stop what will be an ineradicable stain on the national honor?

Hold him in your arms, now you can feel his disease. . .

Probably not. In the glamorous, sexy, and highly lucrative field of medical sociology, we distinguish between disease and illness. (Don't go to your dictionary, this is jargon.) A disease is a label applied by a medical professional, signifying an abnormal and (in the labeler's opinion) undesirable, biological or psychological state or characteristic. In our society, the labelling (i.e., diagnosing) functionary usually holds the honorific of medical doctor and the the office of licensed physician. Also, the distinction between biology and psychology is eroding.

An illness is a set of undesirable sensations and/or limitations experienced by an individual, who attributes them to an abnormal biological or psychological state or characteristic. (Note that the idea of abnormality, in both cases, requires unpacking, but I won't do that now.)

In some cases, disease and illness are closely related and the two perspectives get along comfortably. The doctor tells you that you have osteoarthritis, and the main clinical manifestation is that your knees hurt. What bothers you is that your knees hurt, and you are very satisfied with that diagnosis. Of course, the meaning and consequences of aching knees vary tremendously from one person to another, so that every illness experience of arthritic knees is unique.

Sometimes, the disease and the illness don't get along well at all. The psychiatrist decides that the patient has borderline personality disorder, which he defines as an impaired ability to internalize objects and attributes to emotional neglect or abuse in infancy. The patient believes she is suffering because she has been betrayed and abandoned by a series of untrustworthy and fickle friends and lovers. These are radically different beliefs. Suppose the psychiatrist decided instead that the patient's problem was that she had the misfortune to have been betrayed and abandoned by a series of untrustworthy and fickle friends and lovers. The patient would still be suffering, but would not have a disease. (In practice, the psychiatrist would almost always find a disease label for her suffering, in this case perhaps an adjustment disorder, in order to get paid.)

Sometimes the disease label is the sole cause of the illness. For example, Cervantes was hop-scotching through life, whistling a happy tune, until his doctor told him he has hypertension and hypercholesteremia. Now he has to spend significant energy (and a bit of money) filling prescriptions, taking pills every day that sometimes make him dizzy, worrying about what he eats, etc. People who feel just fine are told that they are HIV positive, and all of a sudden they have an illness that is a major focus of their lives. They have to take numerous pills every day that likely make them sick and even cause bizarre changes in their body shapes; they often feel they must conceal their diagnosis from co-workers, friends, and family members; they worry about what to tell potential sexual partners, who may be repelled if they tell the truth; and so on.

Sometimes the illness is the sole cause of the disease. Doctors get very frustrated by people who come in with complexes of complaints that they can't explain biologically, so they ended up inventing disease labels for some of the most common ones -- fibromyalgia, Chronic Fatigue Syndrome. Some doctors object to these labels, others are searching for biological etiologies (causal stories) for them, and biological markers other than the patients' reported symptoms, which would confirm the "reality" of these diseases.

Sometimes, drug companies try to create disease labels. For example, they are making a lot of money selling various potions to give us guys those four-hour erections we keep hearing about during the time outs, but they are frustrated that they can only sell these to half the adult population. So they have been promoting a disease called Female Sexual Dysfunction, which basically means not having orgasms often enough to meet some arbitrary criterion, in hopes the disease will be generally accepted so they can sell pills to treat it. As Ray Moynihan writes in the British Medical Journal (January 21, 2005), "In the shadows of [the debacle over the non-existent "disease" of post-menopausal hormone deficiency], the pharmaceutical industry is meeting unexpected resistance to its attempts to sell women the next big profitable "disease," female sexual dysfunction. This condition is claimed by enthusiastic proponents to affect 43% of American women, yet widespread . . . disagreement exists over both its definition and its prevalence. "

This is all just a fancy way of saying that there is a fundamental difference in the perspectives of physicians and patients about the very nature of the basic subject matter of medicine. Does this ring true in light of your personal experience?

Public Health in Iraq is not Off Topic

ABC News, bless our fearless guardians of truth and the public interest, has put up a major feature on its web site called Iraq: Where things stand. It is not for this blog to go into all of it (I recommend Today in Iraq), but the supply of clean water is certainly one of the most important issues as far as public health is concerned. Here's what ABC says:

Water Quality Better in Iraq's Cities
Rural Areas Worse Off Regarding Water and Sanitation

Today, water treatment in urban areas is clearly improving, while rural areas suffer disproportionately from a lack of clean water and sewage treatment. Sewage treatment in rural areas is virtually nonexistent and waste often flows directly from these places into the Tigris and Euphrates rivers.

Overall, nearly one in five urban households and three in five rural households still do not have access to safe drinking water, according to recent reports.

It is worth noting that in many parts of the country these problems were severe before the war as well, as the country suffered the effects of U.N. sanctions.

Facts and Figures

Availability of clean water — prewar: 5.25 billion liters/day.
Current: estimated 5 billion liters/day.
Dec '06 (goal): 7 billion liters/day).

The U.S.-led Projects & Contracts Office says it plans to spend $1 billion over the next two years on water/sewage reconstruction. (Source: U.S. Projects and Contracts Office)

Note that the headline does not exactly correspond to the contents of the story. But never mind. Here's what Riverbend says, who actually lives in Baghdad:

There hasn’t been a drop of water in the faucets for six days. six days. Even at the beginning of the occupation, when the water would disappear in the summer, there was always a trickle that would come from one of the pipes in the garden. Now, even that is gone. We’ve been purchasing bottles of water (the price has gone up) to use for cooking and drinking. Forget about cleaning. It’s really frustrating because everyone cleans house during Eid. It’s like a part of the tradition. The days leading up to Eid are a frenzy of mops, brooms, dusting rags and disinfectant. The cleaning makes one feel like there's room for a fresh start. It's almost as if the house and its inhabitants are being reborn. Not this year. We’re managing just enough water to rinse dishes with. To bathe, we have to try to make-do with a few liters of water heated in pots on kerosene heaters.

Water is like peace- you never really know just how valuable it is until someone takes it away. It’s maddening to walk up to the sink, turn one of the faucets and hear the pipes groan with nothing. The toilets don’t function… the dishes sit piled up until two of us can manage to do them- one scrubbing and rinsing and the other pouring the water.

Who do you believe?

Call me soft on crime

Ask Americans what they’re most worried about and what they want from their elected officials, and consistently over the years a lot of people are worried about crime and want the government to get tough on criminals. That’s not hard to understand – watch your local TV news for a while, and you will quickly learn that violent assaults, armed robberies, rapes and murders are the main things going on in your city or county. So we have mandatory sentencing laws, elimination of parole, an end to coddling of criminals with things like education and job training – why should criminals, who have lost any right to respect or help from society, get a free education when my own law abiding kids can’t?

Who are all these vicious criminals filling our jails? Twenty-five to 30% of them have been convicted of drug offenses only, and the vast majority of them are not major traffickers. A full 80% of criminals, including those who have been convicted of property crimes (the largest group), have histories of substance abuse and their offenses are in one way or another associated with substance abuse and addiction. (National Center on Addiction and Substance Abuse at Columbia University. Behind Bars: Substance Abuse and America’s Prison Population. New York: CASA, 1998.) Most people are surprised to learn that the drug most associated with violent crime is alcohol – 50% of violent crime is associated with alcohol intoxication, in fact. (Pernanen K. Alcohol in Human Violence. Guilford Substance Abuse Series. New York. 1991.)

But these aren’t just any old addicts – they aren’t the same people who end up in the Betty Ford Clinic or the college counseling program. They’re mostly people with little education, low literacy, no marketable skills. They started doing poorly in school when they were young and their lives just never got going. They might have learning disabilities, they might have come from unstable or abusive home environments – and oh yeah, when they first started to get in trouble, as kids, the system dealt with them punitively, rather than trying to help them. That was much more likely to happen if they were Black or Hispanic. According to the best available data, Black and Hispanic kids don’t use illicit drugs or commit offenses more often than white kids, but they’re much more likely to end up in the juvenile justice system.

So the cops find a guy selling dime bags, or writing bad checks, or stealing car stereos, and the judge throws him in jail for a year, then they toss him back out on the street, still without education, job skills or experience, and now with a criminal record. What’s gonna happen?

It has been shown that substance abuse treatment reduces recidivism. (Field G. The effects of intensive treatment on reducing the criminal recidivism of addicted offenders. Federal Probation 53(10):51-56. 1989, and other references above). However, according to a CSAT consensus panel, “Many offenders are released with no place to live, no job, and without family or social supports. They often lack the knowledge and skills to access available resources for adjustment to life on the outside.” For released offenders, treatment is much more likely to succeed if it is integrated with other essential rehabilitative services including education, job skills development, housing, family counseling, etc. But most offenders get none of the above.

We can take a bite out of crime. We know exactly how to do it. But we’re spending billions of dollars building prisons and locking people up, which provides employment for prison guards in depressed rural areas but also increases the crime rate. There’s a better use for most of that money, but when was the last time you heard a politician promising to provide substance abuse treatment, job training, education, housing and family counseling to released offenders?

Manly men (and women)

We're still digging out from the three feet of snow here in the Hub of the Universe. Yesterday, with the snow flying horizontally, I decided to encase myself in puffy clothing and take a walk around the 'hood, because I was bouncing off the walls. The main streets had been plowed, kinda, pushing up six foot dikes along the sidewalks, but there were six inches of snow in the streets anyway. All of the businesses were closed, but incredibly, there was a pile of Boston Sunday Globes poking out of a snow drift in front of the CVS. I nicked one. A few fellow intrepid adventurers were also out walking around, in the street of course, you needed cross country skis for the sidewalks.

There was an occasional police car fishtailing around in the snow, ambulances going by transporting snow shovelers with heart attacks no doubt. And uh -- quite a few of my neighbors driving up and down Centre St. in gigantic, honking SUVs. Where were they going? Nowhere, of course, because there wasn't a business open anywhere in Boston, there weren't even any church services (it was about 1:00 pm anyway), and these folks obviously weren't on their way to their jobs as emergency room physicians because a) they were going the wrong way and b) the shifts change at 8:00, 4:00 and midnight.

No, these people were out in the middle of the worst blizzard in history in order to justify to themselves spending $60,000 on a vehicle that weights 7,200 pounds, with 345 horsepower, that gets 13 miles per gallon even though, unlike the people in the ads, they are never going to have their car blown out of a volcano and they are never going to use it to climb Pike's Peak. All year long they drive on nice, paved roads to the grocery store, Muffy's flute lessons, and the hairdresser. But now, for the first time since they bought the Escalade, they can drive around being a menace to society while their neighbor with the Camry can't, or at least prefers not to.

And by the way, 4 wheel drive doesn't prevent it from skidding, and doesn't help it stop. Some of these idiots ended up buried in snow banks and had to be towed out. But thank God President Bush has our boys over in Iraq defending the oil supply so they can keep putting gas in these useless monstrosities.

Frist! (No, really)

Back in May, Senate Majority Leader William H. Frist, M.D., gave the annual "Shattuck Lecture" at Charles Emerson Winchester's beloved Massachusetts Medical Society, entitled "Health Care for the 21st Century." The lecture was published in the New England Journal of Medicine last week.

Senator Dr. Frist is optimistic indeed. In 2015, his imaginary friend Rodney, from Woodbury Tennessee, "lives in a world in which America's leaders years ago made tough but wise decisions." Oddly enough, these tough but wise decisions did not prevent Rodney from having several preventable diseases: diabetes, hypertension, and high cholesterol. He also smoked, it seems, until 2007. But Rodney was as wise as America's leaders: "In 2005, Rodney chose a health savings account in combination with a high deductible insurance policy for health coverage." Yes, Rodney was smart, he bought into the ownership society. None of that pinko homosexual comprehensive health insurance for Rodney!

Frist is not afraid to recite the problems with our current system: highest health care spending of any "industrialized" country; average premium for a family policy is 21% of median household income; 45 million uninsured people; racial, ethnic, geographic disparities in health; etc. "We must agree on a guiding principle: all Americans deserve the security of lifelong, affordable access to high-quality health care."

It's nice to have a princple that says people deserve it, but it's even nicer to have a plan that will give it to them. This, it turns out, Senator Doctor Frist does not have. His system of "consumer driven health care" is driven by consumers in the sense that they pay for it, out of their own pockets. This means that people who earn more than $40,000 per year "should be enouraged, through changes in the tax policies, to buy themselves and their children high-deductible catastrophic insurance coverage." They would then pay for routine care through Tax-free health savings accounts (HSAs). Frist also wants to eliminate the tax policies that encourage employers to provide insurance. He says that the system of employer-provided health care "has been universally blamed by economists for inflating health care costs." However, the reference he gives says no such thing. (Read it yourself at Sheils and Haught.) It does say that the system of tax subsidies is regressive in that it disproportionately favors the wealthy, but the authors do not blame employer-provided health care for inflating health care costs.

It is correct that economists blame our fragmented system for the higher costs here than in other countries, but Frist's solution is to make it even more fragmented. Even for long-term care (which accounts for 30% of Medicaid expenditures) his solution is to make premiums for long-term care insurance tax deductible.

In the real world, which is quite unlike the fantasy world of Republican politicians, the people who establish Health Savings Accounts and buy long-term care insurance -- with the benefit of the tax subsidies Frist wants to extend for these purposes -- will disproporionately be the healthy and the wealthy. These people will no longer be in the pool for comprehensive insurance, the price of which will then rise. Although Frist appears to believe that insurance will be more "affordable" because of competition among providers and health plans, the fact is, they already compete in a market with many large, powerful buyers. By phasing out employer-provided insurance, and leaving individuals to go out and try to buy insurance on their own, this concentrated purchasing power will disappear. Frist's world is a jungle in which the fortunate will be rewarded and the less fortunate will be on their own, unable to pay for health care as young adults or nursing home care should they need it. It is all served up in a confection of sweet lies and distractions, but the real nature of the Ownership Society is clear: We own you.

And more thanks . . .

To everyone else for the bumper stickers -- I saw the rest of yours after I saw Speechless's.

And absolutely, universal health care would be good for business. It's one important piece of what we have to do to keep this country economically viable and innovative. It's one of the most important keys to a real new american century.

GPRA -- or , it's all Al Gore's fault

Many thanks to Speechless for the bumper stickers. Some of them are fanciful, a couple of them definitely have potential. I’m afraid I can’t give her the extra doctor appointments she wanted, but I can say something about an issue she is interested in: how can we show the effectiveness of social service and behavioral health programs, especially for the most troubled and least fortunate?

It is indeed very difficult. These sorts of programs don’t lend themselves very well to that gold standard, the randomized controlled trial. (See archives.) You can’t randomly assign homeless, mentally ill addicts to either be sheltered and fed, receive counseling and substance abuse treatment, and vocational rehabilitation; or be left out on the street and periodically interviewed by a graduate student to get comparison data.

That is not to say that over time and by dint of much qualitative and quantitative investigation, and trial and error, we haven’t gotten some good evidence. Substance abuse treatment along with case management, peer mentorship, support groups, and vocational services, are quite effective in preventing released prisoners from re-offending and going back to jail. Unfortunately, very few ex prisoners are fortunate enough to receive such services. Mentally ill people and substance abusers who receive intensive community based treatment do have a better chance of being stably housed, holding jobs, and maintaining natural support networks – i.e. having relationships with family and friends. For people who can’t get more well or more functional, obviously having a roof over their heads and some kindness and encouragement make them better off..

Even though your program is effective, it is not necessarily the case that most of your clients are going to be better off after six months than they were at the beginning. People with multiple problems including unstable lives, chronic mental illness and addiction, if left to themselves, tend to get worse over time, not better. Of newly released prisoners, many will re-offend. If you record at intake whether they have used illegal drugs within the past 30 days, most of them will say no because they were in jail. After a few months, many of them will relapse; your program will prevent only some of those relapses. So if you do longitudinal surveys of your clients, you will see many of them looking worse off after six months than they did at intake. But it is likely that fewer of them are worse off than would have been the case had your program not been there for them. Furthermore, addiction is a relapsing/remitting condition. It usually takes multiple attempts to stop, and some people never really do although they may maintain longer periods of sobriety in between episodes of abuse, and so achieve better social functioning.

The federal government, as we all know, has largely gotten out of the business of attacking social problems on a scale that might really make a difference. However, thanks to the efforts of the Congressional Black and Latino Caucuses, and their friends, we do have a few “Targeted Capacity Expansion” and demonstration projects. One of these is the Center for Substance Abuse Treatment’s (CSAT’s) Targeted Capacity Expansion program which funds community based organizations to develop and expand substance abuse treatment aimed at people at high risk for HIV. The program targets underserved minorities, particularly African Americans, Latinos, and Native Americans, all of which population groups have a disproportionately high risk of acquiring HIV and Hepatitis C infection due to substance abuse.

To give credit, or blame, where it is due, thanks to Al Gore’s initiative as Vice President to make government programs more “accountable,” we have to live with something called the Government Performance and Results Act (GPRA). Thanks to GPRA, the grantees of these programs have to report on their clients at intake, and 6 month intervals thereafter, including recent illegal drug use and alcohol abuse, their housing situation, their employment situation, etc. CSAT gets mad if the programs don’t get 6 and 12 month follow-up interviews with 80% of their clients – which is extraordinarily challenging with drug addicts. So the programs have to devote a large portion of their resources trying to keep track of people who drop in and out of the program, may be in jail, back in the crack house, in the hospital, or dead. Or, for all we know, working and living happily and soberly, but in Puerto Rico or Oregon.

What is worse, these numbers just don’t tell us whether the programs are effective or not. The average person could be worse off or better off after 12 months, but without anything to compare them to, what do the numbers really mean? Maybe half your clients are worse off, 25% are better off, and 25% are doing about the same. Does that mean your program is a failure? Certainly not, it might be that without it, 75% of your clients would be worse off. And maybe it really takes 2 years for some of them to make it. But when the Republicans in Congress, and the Bush appointees in the Office of Management and Budget, see these numbers, what do you think they will do?

(And sorry for the long post. Here I am asking for bumper stickers . . .)

It's Hard Work

No, I don't mean watching war on TV, or preznitin', though I'm sure those can both be quite challenging for a boy of very little brain. I'm talking about understanding our bizarre, Rube Golberg, byzantine, ramshackle, duct taped-together, accidental, incomprehensible health care system.

This is one of the biggest obstacles to advocating and organizing effectively for reform: the inevitable, eyeball glazing wonkishness of any attempt to explain just what in the delta quadrant of the galaxy you are talking about.

Most people don't know the difference between Medicaid and Medicare. If they do basically get that one is for poor people and one is for old people, they don't know about disabled people and they also don't know that a big chunk of Medicaid spending actually goes to people on Medicare, and if you tell them that, it doesn't make any sense to them and trying to explain why takes another 20 minutes. People don't understand the eligibility requirements, the benefits and limitations, how they are financed, state vs. federal administration . . .

And people don't understand very much about their employer-provided insurance either: how markets for health insurance work, what managed care is all about (what's left of it), how their doctors are paid, why it all costs what it does . . .

A while back I was involved in an organization working for a single payer plan in our state. We quickly realized that you can't put "single payer health care" on a bumper sticker. Nobody knows what that means, or why they should be for it, and if you try to explain it to them you've lost them after the first half hour or so. The main reason the Clinton plan went down in flames is that nobody could understand it -- including me, by the way. I had a number of questions that nobody could answer to my satisfaction, about people living in Rhode Island and working in Connecticut, flying up from Florida to Jackson Hole and breaking their leg there, who the hell was going to manage and figure out and supervise the spaghetti bowl of cash flows among all these hundreds of regional "alliances," how to stop the plans from cherry picking and all the other perverse incentives built into this gigantic junk pile.

Yes, we need universal, single payer national health care. But as soon as we make a serious proposal, Harry and Louise are going to be on TV making simple, straightforward and dishonest accusations about "rationing health care" (gasp! how immoral), and raising your taxes, and layers of bureaucracy, that it's going to take us six paragraphs of dense prose to refute.

So I'm having a bumper sticker contest. What are the slogans? What are the punchy, understandable messages that can beat Karl Rove at his own game?

Also, if there is popular demand, I will post a primer on the current system, but only if asked.

The American Century is Over, Part 4: That old time religion.

In domestic affairs, the cabal espouses an ideology often called Free Market Fundamentalism. This begins with the proposition that whatever property people happen to possess at this moment has a fundamental moral status: that ownership is morally justified, as is the deprivation of those who do not possess much property. The disadvantages for acquisition of those who are impoverished, and the advantages for those who are wealthy, are also an unassailable virtue. This moral principle is embedded in a theoretical edifice developed by economists.

Economics is theology, not science. The basic method of economists is to draw up a list of assumptions which are contrary to fact, or at the very least have not been established. From these assumptions they spin a web of deduction about how the world would work if the assumptions were true. Somewhere along the way, they forget that the assumptions are false, and start to believe that they are describing reality. To the extent that the discrepancy between their fantasy world and reality is too obvious to ignore, they try to modify the system by introducing corrective factors. This was also, of course, the method of Ptolemaic astronomy – to keep adding cycles and epicycles to make the motion of the planets around the earth correspond to observation.

I’ll deconstruct the epicycles in a future post, but for now, here’s a quote from Mr. Bush:

One way you can create jobs is to lower people's taxes. (Applause.) If people have more money to spend, it means somebody has got to produce more for them. And the producers then need to hire people. It's economics 101. Except sometimes people in Washington haven't taken the course.

This sounds compelling, until you realize that government doesn’t take the tax money and burn it on the altar of liberalism. Government, yes, spends the money! With some of that money, government actually hires people directly. Those people then have jobs! Some of it, government invests in infrastructure, research, and other enterprises that not only create jobs immediately, but create the foundation for a vital economy into the future. Government pays for health care for elderly people and poor children, which not only creates jobs in the health care industry, but helps make those children more productive as adults. Government pays for environmental regulation that not only employs scientists and regulators, but keeps the whole population healthier so they can, yes, work! And some of it, government puts in the pockets of retired people who, yup, spend it.

Agreed, some of that money, government squanders in a way that hurts the economy. Mostly, that’s by using it to buy aircraft carriers, fighter jets, nuclear submarines, 30 million dollar tanks, etc., which then sail and fly and drive around the world either doing nothing in particular or blowing up stuff and people. But Mr. Bush loves to shovel borrowed dollars down that rathole because it makes him feel all world historical ‘n stuff.

So no Mr. President, it isn’t Economics 101. Or rather, maybe it is. Universities pay big salaries to tenured professors of economics to fill the heads of freshmen with nonsense.

What Mr. Bush likes is for rich people not to have to pay taxes. He doesn’t give a rats ass whether workers in Indiana have jobs. If he did care about them, he wouldn’t be shooting people and blowing stuff up in Iraq while Indiana’s jobs head off to China and Indiana’s grandchildren pile up trillions of dollars in debt to those same Chinese who are taking their grandparents’ jobs. He’d be doing something about it. But he doesn’t care because he and his rich friends can invest their money anywhere they want to, in Europe, in Asia, in those very same U.S. Treasury bonds your grandchildren will work all their lives to pay off.

But Joe Hill told us why the good people of Indiana scream and shout and applaud and vote for Mr. Bush:

Work all day,
Live on hay.
You’ll get pie
In the sky
When you die.

The song is called The Preacher and the Slave.

Next installment: What to do.

Getting our Priorites Straight; or, What A Crock

It seems some guy called the California state police, anonymously, and claimed that four Chinese "scientists" and two Iraqis were heading to Boston to set off a "dirty bomb" (an explosive with some sort of radioactive isotope included that would contaminate a small area with low-level radioactivity). The Governor of Massachusetts flew home immediately (poor guy, he'll miss the inauguration, what a heroic sacrifice). The Mayor held a press conference. The TV news talked about nothing else -- well, okay, they also talked about the Patriots. The newspapers all have screaming banner headlines.

Personally, I consider the actual probability that four Chinese and two Iraqis are coming to Boston to set off a dirty bomb to be in the general vicinity of the probability that an asteroid is going to hit City Hall this week. But I do know this with 100% certainty:

1. 13,000 children in Massachusetts are lead poisoned every year;
2. A baby dies in Massachusetts once a day, on average;
3. Somebody dies of HIV/AIDS in Massachusetts once a day, on average;
4. 2 people die in Massachusetts in car crashes on an average day;
5. 1 person takes his or her own life in Massachusetts every day, on average;
6. 4 people die from other causes of injury, often on the job, on an average day in Massachusetts;
7. 4 people die every day from diabetes in Massachusetts, most of them from Type 2 diabetes which is completely preventable;
8. 10 people die from stroke, 38 from cancer, and 40 from heart disease, every day. Many of those deaths are premature -- they could have been prevented;
9. About 150 people are murdered in Massachusetts every year;

I don't see the Governor flying home to do something about any of this, I don't see the Mayor calling press conferences, and I don't see the headlines. Oh yeah, maybe I do see headlines for the murders, though I don't see any thoughtful consideration of why homicides happen.

Well, nothing more to say on this, except that Massachusetts is one of the healthiest states, with a comparatively low rate of premature mortality. I don't think those dirty bombers are going to change that, even if they do show up and do their worst. But the stupidity of our leaders and our mass media might.

New info on uninsured in one state

Massachusetts is wealthier than most states, and has a relatively generous Medicaid program. Nevertheless, it is similar to most states in the kinds of disparities that exist in health insurance coverage and the correlates of lack of insurance. It is also exceptional in the resources it invests in collecting data relevant to public health policy, including a periodic, high quality telephone survey on health insurance coverage.

The report is out for 2004. Highlights include:

Huge racial and ethnic disparities in insurance coverage:

• "Black, non-Hispanics" (which in Mass. include significant numbers of Hatians and Cape Verdeans as well as African Americans) are about twice as likely to be uninsured as "White, non-Hispanics."
• "Hispanics" are about three times as likely to be uninsured.

60% of employees of small firms are uninsured!
The percentage of the state's population that was uninsured went up significantly from 2003 to 2004, because people lost employer-provided coverage.
Uninsured people were much less likely to have visited a doctor or a dentist in the past year.

The report, and past years' reports, are available here.

(By the way, Blogger is eating posts lately, this is my second try. Any fellow bloggers having the same problem, let's send 'em nasty e-mails.)

The American Century is Over: Part 3, the Imperium

I may seem to be off topic, but I want to make full disclosure of the beliefs that underly my part of the discussion here.

State power in the United States has been seized by a cabal whose association goes back to the Reagan Administration, although they recruited George W. Bush to be their figurehead more recently. They have the support of a many powerful elites, who gain various advantages and favors in return, and of a large segment of the electorate, but I will not analyze the basis of their current power here, though I may touch on it incidentally.

To a large but not precisely knowable extent, their publicly stated beliefs, intentions and rationales are a carefully woven tapestry of falsehood. This can be shown in part because what they said quite openly when they were out of power during the Clinton administration and what they say as campaigners and office holders are quite different. It is also evident because much of what they say is demonstrably false and they surely know that. Finally it is evident because of internal contradictions, the flaws in the tapestry. This complicates the task of writing a succinct critique of the destructive path down which they are leading us, so I ask the reader not to demand that I fill in every blank. This is a blog, not a book.

First, they understand U.S. influence in the world, and the national interest in foreign affairs, as a function of military power. During the Clintonian exile, they called quite openly for U.S. military domination of the planet, starting by invading Iraq in order to establish military hegemony in the Middle East. (Go here for the story.) They knew, however, that the public did not like to think of the United States as an imperialist power, so they tarted up their call for domination as “spreading democracy.” Everybody knows, however, that freedom and democracy do not issue from the barrel of a tank or rain down as shrapnel from a 500 pound bomb. By freedom and democracy they mean regimes friendly to the United States. Even so, they knew that the public would not accept their project without a transforming event, a “new Pearl Harbor.”

Although GW Bush campaigned in 2000 on a platform of humility in foreign policy, we now know that he and the cabal wanted to invade Iraq on the day he took office. They got their new Pearl Harbor on Sept. 11, 2001, but it took a massive campaign of lies to turn public anger and fear over that event against the irrelevant regime in Iraq. At the height of the war fever, it seemed that the idea of an American imperium could be sold to the public after all. Supposedly learned savants were all over the airwaves promoting the Obligations of Great Powers and the Legitimacy of Empire, as a means of bringing order and stability to a dangerous world. The disastrous results of the war are now evident, and all of this yammering has abruptly vanished. But what was their real motivation?

It is, of course, their response to the problem of dependence on foreign petroleum resources. But their motivation has nothing to do with the health of the U.S. economy or even the national interest of the United States, however conceived. American businesses and consumers, after all, could have purchased petroleum from Saddam Hussein as easily as they would have bought it from the fantasized Ahmad Chalabi regime. What concerns the cabal is the value and profitability of the American oil companies that support them politically and enrich many of them personally.

That is why the first order of business upon occupying Iraq was to secure the oil infrastructure and move to exclude the French and Russian companies who had previously been Iraq’s partners in oil extraction. And it is why the second order of business was to begin the transfer of billions of dollars of revenues from sale of Iraqi petroleum and the seizure of state assets into the coffers of U.S. corporations, notably but not exclusively Vice President Cheney’s employer Halliburton, ostensibly for “reconstruction” work, which was never done. It is also why they are so committed to exploiting the oil fields in the Arctic National Wildlife Refuge, and removing environmentalist restraints on oil field development elsewhere, even though domestic production cannot, under any circumstances, contribute significantly to reducing the dependency problem.

It is also why they have no interest in reducing consumption of petroleum or other fossil fuels; deny the reality of global warming; want to weaken fuel economy standards, clean air protections, mass transit subsidies, and other measures that could reduce demand for petroleum; and most certainly would never consider raising taxes on fossil fuels. They are in the oil business. That is the interest they work for and defend. And they have friends and contributors in other industries who they also work for. The interests of the people of the United States are no concern of theirs.

Next: Economic and social policy

As Atrios would say . . .

Oy.

Gregg Sees Medicare, Medicaid Cuts as Only Way to Resolve Deficit Problem
January 14, 2005—Judd Gregg, the incoming Senate Budget Committee chairman, took the job in large part because he wanted to tackle the burgeoning cost of entitlement programs including Medicare and Medicaid, something that he views as the only way to bring long-term budget deficits under control.

In a series of media interviews last week, Gregg talked a tough game on the budget, putting entitlement savings on the table as lawmakers contemplate the first serious attempt since 1997 to bundle savings from mandatory programs into a budget reconciliation bill aimed at curbing the deficit.

"I don't think you can effectively address federal spending unless you address entitlement spending," Gregg, R-N.H., said in an interview with Congressional Quarterly on Jan. 11.

As it turns out, however, GOP budget writers are likely to largely leave alone the Medicare health care program for the elderly, according to Gregg and senior congressional aides in both parties. Instead, they are likely to tap the Medicaid health care program for the poor for savings.

From the Commonwealth Fund. Link here

The American Century is Over: Part 2

As the American Century came to a close, the United States, despite its immense wealth and power, faced some daunting challenges. While these were apparent to many well informed people, who were actively raising alarms, they went almost unmentioned in political debate and in the corporate mass media. Public discourse focused on trivia at best, often on complete falsehoods, and perhaps worst of all, on the irrational obsessions of people who wanted to lead society into a dark age of superstition and willful ignorance.

class="MsoNormal">What were our real challenges? First, the immense prosperity of the industrial age, on which the power of the United States rested, was largely fueled by petroleum. The U.S. had already consumed most of the petroleum within its borders and could not possibly expand production enough to reverse the steady rise in oil imports. The earth is not about to run out of petroleum any time soon but due to rising global demand as the economies of China and India expand, and the increasing difficulty of extracting petroleum from ever more remote and difficult places, the price will inevitably rise. Unless demand can be reduced, it will keep rising, into the indefinite future. (It is possible that the absolute rate at which oil can be extracted globally will soon begin to decline, but that is actually not important in itself. What matters is the relationship between supply and demand.)

Furthermore, the dependence of the U.S. on imported oil is disconcerting because of the possibility that political instability in oil producing regions, or international conflict, could disrupt supplies.

Supply aside, burning fossil fuels causes a lot of harm, as everyone ought to know. Even if petroleum supplies are limited, there is one hell of a lot of coal in the world – enough to fuel the industrial economy for hundreds of years, in theory. (Most of it is in Siberia and China.) But that is not a solution. Burning coal puts more carbon dioxide, sulfur, soot and other pollutants into the atmosphere than burning oil does. Converting coal into compact, liquid transportation fuel requires using even more coal and creating more pollution. Environmental limitations require that the world reduce its consumption of fossil fuels, not increase it.

A second major problem facing the United States was the impact of global economic development on its workers. Capital, and now goods, cross borders as freely as the wind, but workers are tied to their homes. American workers can no longer expect to be paid $20 and hour, or even $7.50, for factory work that people elsewhere will do for one or two dollars a day. Today, an endless conveyor of container ships pours manufactured goods into West Coast ports, and then returns to Asia filled with scrap metal and rags. Tens of billions of dollars flow out of the United States every month, to purchase manufactured goods and petroleum, and then flow back to purchase debt instruments of the U.S. government, which we and our children and grandchildren will have to repay. We are eating our seed corn.

Then there is what is often referred to as the demographic problem – the aging of the population and the increasing dependency ratio that goes with it. As with all of our problems, the real nature of this one has been grossly misrepresented. Our public pension program for the elderly (and disabled), Social Security, is affordable, assuming we can preserve our economic vitality. However, rising health care costs threaten to swamp our economy and our publicly funded systems of health care insurance. This problem does not exclusively pertain to the aged but the aging of the population certainly contributes to it.

These could all be called structural or exogenous problems. They arose because of forces that were inevitable, not under the control of the United States, although we certainly could have anticipated them a long time ago and taken appropriate steps to ameliorate them. We have failed to do so, and they have grown far more difficult. However, we have also proactively contributed to our problems. Notice, for one thing, that I have not mentioned "terrorism" yet -- now you know why.

I will discuss the folly of our leadership and the culture which has enabled it in the next installment, before turning to the necessary solutions in part 4.

The American Century is Over

I am determined to keep this site on topic, but it isn’t easy. We are cursed to live in interesting times, and many subjects demand attention. Times are so interesting, in fact, that we cannot understand the prospects for the public health without considering the grand historical context.

The 20th Century was truly the American Century. It was the century when the United States, thanks to struggle, courage and sacrifice, became better. Women achieved the full legal status of persons, and while we are still far from true equality between men and women, we are indisputably much closer than we were in 1919. Workers died as numerous and nameless as flocks of starlings, in mines, factories, and farm fields, crushed, mangled and poisoned; machine gunned by police, soldiers, and mercenary armies; beaten to death by goons. But in the end they won the basic dignity and decent life we take for granted today: The descendants of slaves, spilling rivers of their own blood, at last also won legal recognition of the fullness of their humanity and citizenship.

As a people and a polity, we recognized that liberty does not only mean freedom from oppressive government. It also requires democratic government that actively defends the people’s liberty -- from private rapacity that would despoil our common heritage and crush the weak, from deprivation in sickness and old age, from bigotry and communal conflict, and from gross inequality of means and opportunity.

The United States also became a dominant and generally admired force in the world. Our leaders made many mistakes and committed many atrocities, but we are still honored for mobilizing our entire society to save the world from Hitler and Imperial Japan. The same African Americans who inspired the world by their struggle for equality gave the world the definitive musical language of the age. Our movies, our literature, our scientific discoveries and technological achievements enriched all of humanity. In spite of the frequently hypocritical, exploitive and crudely self-interested actions of our governments toward weaker countries, the U.S. still managed to acquire a store of moral authority, at least for its stated principles. And our dynamic, innovative economy created a resource base that made Americans believe in limitless possibilities.

Some of our accomplishments with the most direct and obvious relevance to public health included the National Environmental Policy Act, the Clean Air Act and Clean Water Act; Medicare and Medicaid; and the development of the Centers for Disease Control and Prevention and its U.S. Public Health Service into the world’s most capable and effective public health agency. In many respects we continue to fall short of the public health accomplishments of other wealthy countries, but that is mostly because we continue to have more inequality and a weaker social safety net than they do. Nevertheless the United States grew more than wealthy enough to solve these problems, and for a time, it appeared the will might be there to do it.

Now, tragically, disastrously, all of these accomplishments are being squandered and destroyed. Our wealth is being plundered, our progress as a society reversed, our people impoverished, our influence in the world demolished, our freedoms stolen, our future blighted. How has this come to be? What must be done to reclaim our national heritage and win back our future? I will address these questions tomorrow.

Right makes Rights?

The International Covenant on Economic, Social and Cultural Rights, adopted by the United Nations in 1966, theoretically binds nearly all the nations of the world. Article 12 begins:


1. The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

Chiseled into the facade of the main building of the Harvard School of Public Health, in more than a dozen languages, are the words: "The highest attainable standard of physical and mental health is the right of every human being."

This is a noble sentiment indeed. It appears to represent the strongest possible statement of humanist ethics.

So what does it mean?

• How would we define the "highest attainable standard"?

• What is highest?
• What is attainable?

• How would we measure everyone's physical and mental health, and decide that it conformed to the highest attainable standard?
• What would we do about it if it didn't?
• And what would a world look like in which this commitment was actually honored and this highest attainable standard achieved?

More on the Rule of Rescue

The excellent comments on the previous post made me realize that the Rescue problem often presents as at least two entangled ethical questions. The commenters tend to refer to cases in which the potential state of life of the rescued person is likely to be very poor, possibly very short, possibly even questionably a living state at all.

And these are indeed the kinds of situations in which the Rule of Rescue usually comes to public attention, as in the Terry Schiavo case in Florida. As most of you will remember, this is a woman who is in a so-called persistent vegetative state following a heart attack, whose husband wished to have her feeding tube removed. Her parents objected, and Jeb Bush got a special law passed specifically for this case that permitted him to overrule Mr. Schiavo's wishes. How people feel about this case largely depends on how they define "human life," and what value they place on the continuation of Terry Schiavo's biological functions (to put it perhaps too starkly for some).

While I encourage continued discussion of the question of how we define human life and how we should value life that is very limited, the Rule of Rescue can also be problematic, sometimes even more so, when the subject actually has good prospects for life after rescue, but the cost of rescue is high.

The problem arises when we try to apply utilitarian ethics. Essentially, we have limited resources, and to most people it seems like common sense that we should try to expend those resources to somehow maximize the total good. Of course what we think constitutes maximum good depends on our values, so welfare economists try to quantify the value of states of health and longevity by surveying the public. "How many days or months of total life would you give up to avoid being deaf and blind for five years?" and similar kinds of questions. They actually came up with a unit called a Quality Adjusted Life Year, or QUALY. For example, a year on dialysis is worth .57 of a year of perfect health.

So, let's go back to Belynda Dunn. Although she was HIV+, she did not have AIDS and with the benefit of antiretroviral medications, she had a good prospect of many years of productive life had she received her liver transplant. Her health would not have been perfect of course. Anti-retroviral drugs can have very unpleasant side effects, they usually don't work forever to stop the progression of HIV disease, and she would have had to take immunosuppressive drugs, increasing her risk of suffering from immunodeficiency and eventually, AIDS. Nevertheless she did not want to die and she was fully prepared to accept life on those terms. Her friends also wanted her to live.

The problem here is not that she was beyond help. Tthe problem, to put it bluntly once again, is that $500,000 is a lot of money. Many people say simply that human life is beyond monetary value, that if we can save someone's life we have a moral obligation to do it and money be damned. But in fact, the people who say that don't really mean it. Those 29,000 children under five are dying every day (See "The Silent Tsunami") who could each be saved for a few dollars. But the people who insisted on spending $500,000 for Ms. Dunn's liver never even thought about coming up with five dollars for an anonymous infant in Mozambique who hadn't had a measles shot.

There is a lot to think about here. If we sat down and tried to figure out how to spend our resources to maximize the QUALYs of all humanity, or just our own community if that's where our ethics lead us, we would have to let a lot of sick people, who could be cured, die. We would allocate our resources to the youngest and healthiest people, where we would get the most QUALY bang for our buck by doing inexpensive things to prevent sickness and extend good health, and we would spend relatively little on the sick and the old. But in fact we do the opposite.

Are we doing right, or wrong?

The Rule of Rescue

It has no doubt occurred to readers that there are some knotty ethical problems underlying some of the issues we have discussed recently. In The Silent Tsunami I pointed out that 29,000 children around the world, mostly in poor countries, die every day from readily preventable causes -- a tusnami's worth every two or three days -- but that there is no outpouring of media attention, public or private donations, or aircraft carriers heading out to rescue them. In The Crux of the Matter I pointed out that we'll readily spend hundreds of thousands of dollars on organ transplants and other procedures that may give a few months of limited life to someone, while we don't spend much smaller sums that could prevent many cases of premature illness and death.

There are many comparable situations. A caravan city of TV vans will materialize in some country town when a child falls down a well. Although children suffer accidents every day, we can't predict which ones it will happen to and we pay little attention when it does.

Consider the case of Belynda Dunn, a 42 year old woman who worked as a health educator and counselor for AIDS Action Committee. She was infected with HIV and Hepatitis C Virus (HCV). [1] Her physician determined that she had end-stage liver disease. He told her that she would die within a few months without a liver transplant.

However, Ms. Dunn's insurance company, Neighborhood Health Plan, refused to pay for the transplant, on the grounds that the procedure was experimental in people with HIV. NHP is a non-profit company that does most of its business with MassHealth, the state's publicly funded insurance program which covers Medicaid beneficiaries and people who are eligible for other public health insurance programs such as the Supplemental Children's Health Insurance Program. NHP also has commercial clients, mostly non-profit organizations like AIDS Action Committee that purchase coverage for their employees.

The next day, Aids Action Committee called a press conference to denounce the decision. Boston Mayor Tom Menino announced the creation of a fund called the Belynda Dunn Life Fund, to pay for Ms. Dunn's transplant and, he said, others in similar circumstances. NHP then contributed $100,000 to the fund, toward an estimated total cost of $250,000-300,000. Other donors soon brought the fund up to over $200,000. Speaking from her hospital bed, Ms. Dunn told reporters, "It isn't right that an insurance company can decide whether someone lives or dies." Later, it developed that the amount needed was actually $500,000. The surgery would not be performed unless the full amount could be raised. Ms. Dunn's supporters continued to campaign to raise the money, or force the insurance company to pay. As it turned out, in the end a suitable donor could not be found and Ms. Dunn died.

Now, for $500,000, many cases of HIV could be prevented, and for that matter, most if not all of the 29,000 children who died avoidably on the same day Belynda Dunn died could have been saved. But neither Mayor Menino, AIDS Action Committee, Neighborhood Health Plan, or the donors to Ms. Dunn's charitable fund thought to help them. And consider this -- if NHP had paid the $500,000 for Ms. Dunn's liver transplant, where would the money have come from? It would have meant that several hundred poor children could not be covered by the SCHIP program (which is not an entitlement but has a budgetary limit).

A.R. Jonsen, in 1986, coined the term "The Rule of Rescue." John McKie and Jeff Richardson succinctly define this as "The imperative to rescue identifiable individuals facing avoidable death, without giving much thought to the opportunity cost of doing so." Note the key phrase, "identifiable individuals." Statistics don't move us. Those 29,000 children dying every day are scattered around the world. We don't know who they are, we don't know where to find them. In the tsunami, however, the dead and injured and orphaned children were all conveniently piled up together where TV reporters could find them and cameras could film them, just as they could interview Belynda Dunn but could not identify which children would be denied insurance by NHP because of her liver transplant.

So how about this. Is it wrong to let an identifiable suffer or die who it is possible to save? Was NHP wrong to refuse to pay for the procedure? Were they callous, were they inhumane? Is there a way out of this problem?

I'm asking, not telling.

---

[1] People are often co-infected with these two viruses, which have similar modes of transmission. HCV infection is usually incurable, but the virus can remain latent and not cause problems for some time. When the disease does progress, it can destroy the liver, as in Ms. Dunn's case.

You got questions, we got answers

Yes, we do requests.

A reader asks for specific international comparisons on spending for health care. The Organization for Economic Cooperation and Development -- an association of relatively affluent countries -- has this info.

Health Spending in Most OECD Countries Rises, with the U.S. far Outstripping all Others

03/06/2004 -

OECD Health Data 2004, the most comprehensive source of comparable statistics on health and health systems across the 30 member countries of the OECD, shows that U.S. health expenditure grew 2.3 times faster than GDP, rising from to 13% in 1997 to 14.6% in 2002. Across other OECD countries, health expenditure outpaced economic growth by 1.7 times. In the United States, health spending reached $5267 per capita in 2002, almost 140% above the OECD average of $2144 and around 10 times as more than Mexico and Turkey, which spent $553 and $446 respectively.

Full details here: OECD

Another reader asks about retail pharmacy economics. Does your corner drugstore (probably part of a huge chain, of course) make more money from generic than from brand name drugs? I haven't been able to find hard numbers on this (you probably need a Wall Street analyst type for that) but qualitatively, it makes sense. Pharmacy chains insist, and analysts seem to agree, that they have no price negotiating power with manufacturers of brand name drugs. The big purchasers -- health plans and state Medicaid programs -- do negotiate prices for brand name drugs, and the pharmacists then are allowed to tack on a fixed $2 or $3 to what they pay the wholesaler for filling the prescription. However, there is competition among manufacturers of generic drugs to sell to the chains, so the chains can do some dickering and probably improve their margins. Retail pharmacies prefer to sell generics, that much is clear. Of course, where the retailer does best is with OTC meds, where their margins are not restricted. Also, ironically, they charge whatever the market will bear to uninsured people buying prescription drugs, which is always more than what insurers reimburse.

Finally, a question about the possibility of a major killer flu epidemic (with a link in the comments to the previous post). There is an interesting article about this in the new Scientific American. Researchers have recovered samples of the 1918 killer flu virus and are determining the specific characteristics that made it so virulent. Their best guess about the origin of the 1918 virus is that genetic components of an avian flu virus recombined with strains more infectious to mammals in pigs. Particularly dangerous strains of flu can certainly arise in this way again. New strains of flu generally arise in Asia, where there are a lot of fowls, swine and humans in close proximity. Concerns about avian strains jumping to mammals happen every year. It's really a question of when, not if, but the smart people in the white coats are trying to learn more about what makes flu strains nasty before the next big one hits. That's about all anyone can say about it.

Note that influenza kills tens of thousands of people in the U.S. every year, as a matter of course. Most of them are old and frail, or already sick for some other reason. The 1918 flu, however, was different because it killed a lot of young, healthy people.

The news media generate tons of hype about West Nile Virus and Eastern Equine Encephalitis and other really trivial infectious diseases every year, just because they are novel or rare. Flu overwhelms these media darlings in importance, but we're accustomed to it so it doesn't get the attention. West Nile Virus is very close to nothing, by the way -- if you live in a place where it has become endemic, you've probably already had it, and you didn't even know it. Now you are immune for life. Don't worry about it, it's just an excuse to spray insecticides around, which do far more harm than WNV.

Spinning away

Here's the abstract from a new article in Health Affairs, based on HRSA statistics. They make it sound like good news.

TRENDS

Health Spending Growth Slows In 2003

Cynthia Smith, Cathy Cowan, Art Sensenig, Aaron Catlin and the Health Accounts Team The pace of health spending growth slowed in 2003 for the first time in seven years, driven in part by a slowdown in public spending growth. U.S. health care spending rose 7.7 percent in 2003, much slower than the 9.3 percent growth in 2002. Financial constraints on the Medicaid program and the expiration of supplemental funding provisions for Medicare services drove the deceleration. U.S. health spending accounted for 15.3 percent of U.S. gross domestic product in 2003, an increase of 0.4 percentage points from 2002.

This "slow-down," which was achieved largely by dropping people from the Medicaid roles, still leaves spending on medical services at a new, all-time record as a percentage of GDP (and in absolute terms as well, of course).

Never forget -- this is on the order of twice as much as other wealthy countries spend. And for all the talk of how our health care is the "best in the world," we are the only wealthy country that leaves people uninsured, and the important health status indicators show that the U.S. is close to the bottom among the wealthy countries.

Social Security does not constitute an "imminent crisis," but this does. Does it ever.

Professional boundaries

A few days ago, a visitor raised the question of how our doctors know us -- whether as people, or as patients. This is one of the most important ideas in sociology, sometimes labeled with the German words gesselschaft and gemeinschaft (essentially, society and community), because it was discussed early on by the German pioneer Max Weber. In villages, everybody knows everybody else as whole persons; we have our specific relationships with relatives and friends, of course, but we are able to see each other in full context.

In a modern, complex society, most of the people we interact with are not whole persons to us. We just slot together specific role relationships with them: teacher/student, customer/store clerk, speeder/state trooper, boss/subordinate, etc., and of course, doctor/patient. Given time, fortune and personal compatibility, some of these relationships may broaden out and become more "whole," but the vast majority of them never do.

Many people wish that their doctors could be like Marcus Welby: a neighbor and friend. But usually, nowadays, this is not possible. As a basic practical matter, doctors have thousands of patients; they cannot know them all intimately. In defense of their own sanity, doctors cannot be personal friends of their patients because the emotional burden would be unendurable, as would the ethical dilemmas and the conflicts of interest. Learning to compartmentalize, to distance oneself from the burden of suffering and dying patients, is an essential part of becoming a doctor. There just isn't any other way to do the job.

On the other hand, we have needs for reassurance, emotional support and sensitivity from our physicians. And we need for them to understand us, in some ways at least, as people. Our illnesses -- our lived experience of the malfunctioning of our bodies and psyches -- are not the same as our diseases -- the biological processes that doctors are trained to understand and influence. Diagnosing and fixing diseases often goes awry because of failure to understand what they mean as illnesses, and why and how they arise in our lives. Eliott Mishler, in The Discourse of Medicine, Howard Waitzkin in The Second Sickness, Alexandra Dundas Todd in Intimate Adversaries, have all shown, in different ways and from different perspectives, how cure fails when healing is absent.

A great struggle is underway within the medical institution nowadays to understand what kind of relationships between doctor and patient are most effective for diagnosis, cure and healing; what kinds of people make good doctors; and how to train doctors to at least act more like those kinds of people, even if they can't really be them. How should doctors and patients know each other, listen to each other, feel about each other? Where should the boundaries be drawn, and how much of each of us should be brought inside those boundaries?

AARP un-sells out -- kinda

My parents and their friends all got together to burn their AARP cards after that organization decided, what the heck, We're All Republicans Now, and endorsed the BushCo Medicare prescription drug benefit. As I touched on a couple of weeks ago, and has been discussed a bit in the comments, this multi-trillion dollar transfer from the taxpayers to the drug companies still leaves the most vulnerable seniors with unaffordable medication costs, while forbidding CMS (the Medicare administering agency) from using its purchasing power to negotiate lower prices.

AARP may have gotten the message, kinda. The organization is now categorically rejecting Bush's proposal to phase out Social Security while moving to defend Medicaid and Medicare. According to the Commonwealth Fund,

On Medicaid, AARP said "we fully recognize the budget pressures at the federal and state levels, and we will support changes to make Medicaid more efficient." But AARP "strongly opposes 'reform' efforts that would undermine the key role Medicaid plays in helping our most vulnerable citizens," including block grants.

Novelli said that as baby boomers age, there is an even greater need for long-term care, including less expensive home- and community-based care. "I am pleased to serve on the newly formed National Commission on Quality Long Term Care," he said.

The nation faces a fiscal threat not because of Medicare and Medicaid but because of the underlying problem of rising health costs, [AARP CEO William] Novelli said. "Demography is not destiny and it's not the big problem," he said. "The entire health care system faces these pressures. The most significant step we can take as a nation is to bring health care costs under control."

snip

In addition to espousing Medicare drug coverage, AARP plans to tackle the pharmaceutical access issue with a focus on drug pricing. To that end, it will spotlight price hikes and work for greater access to lower-cost imported drugs. The group also plans to push for setting spending according to evidence-based reviews of which products provide good value and pursue litigation "where warranted."

Asked for specifics, Novelli noted that AARP has litigated in the past to prevent restraint of trade in the generic drug market. No suits are imminent, "but that is part of how we go about social change."



So, they can't exactly admit that they were wrong to back the Administration Medicare prescription drug bill, which does tie their hands on going on after drug pricing directly. But when they talk about bringing health care costs under control "as a nation" there is only one thing they can possibly mean, if they are serious: national health care, and negotiated prices.

Here's the Commonwealth Fund newsletter: Commonwealth

Is there hope for AARP? Stay tuned.

Stayin' Alive

I wanted to say a couple of things about this blog.

First, and most important, I am so impressed and gratified by the comments. I hope that every visitor will read them, the commenters say so many things better than I can. And I also hope more people will begin to participate in the conversation.

One of the main reasons I started this project was because I, and others, would frequently post diaries on Daily Kos about public health and health care policy, and they never seemed to get enough recommendations to stay around. People there are mostly interested in other important issues -- and I agree that we face a crisis of democracy in the U.S. But I am convinced that the public health perspective is the most effective way to talk about issues of justice, equity and the future quality of life for Americans and for the world, and that if we really want to build an effective progressive movement, we have to emphasize the problems we talk about here and we have to organize around them.

Some of the commenters have already started to say all that. So let's continue that discussion -- about political strategy as well as policy and ethics.

At the same time, I do plan to continue to talk about the micro-level -- the culture of the medical institution, how doctors relate to patients, how people can advocate for themselves and the people they care about effectively. To some extent, these are all shaped by the political and institutional context, but there is also an irreducible importance to culture which can't be addressed through politics. Outlawing racial discrimination didn't eliminate racism, and giving women equal legal rights didn't eliminate sexism. The health care system, no matter what we do to eliminate financial barriers, mandate that people be treated fairly, and emphasize wellness, is still going to be hierarchical, paternalistic, culturally inaccessible, incomprehensible and frequently inhumane if we can't reform the culture of medicine.

As for public health, that is really a way of talking about the common good -- about a society that is right for human beings: a society that is just, humane, and meets people's needs, not just their material needs but their emotional and yes, spiritual needs. (And I am an atheist who has no problem talking about spirituality.) So we have a broad enough scope here, I think.

Finally, I want to address my using a pseudonym. Like most people in my business, I depend heavily on federal funding. I could just say that anyone who isn't paranoid right now must be nuts, but in fact I have been given very specific instructions by federal employees (friendly ones) about things I mustn't say. For example, I am not allowed to advocate for needle exchange. I am very strongly in favor of needle exchange -- and the harm reduction philosophy in general, "harm reduction" also being a phrase I am not permitted to use -- and many other enlightened approaches to public health which the "Christian" thought police in HHS are working to purge from legitimate discourse. Consequently, I felt it would be a courtesy to my employer, and would assure that I never had to hestitate about speaking my mind, if I distanced my identity here from my regular professional identity.

My secret identity is no secret, however. It's easy to track me down, if you want to. And in the appropriate forums, and using the appropriate professional language, I will say exactly what I have to say under my own name, as I have been doing. I just want to keep this space with a little extra freedom, at least for now.

The Silent Tsunami

After initially pledging $4 million for Asian disaster relief, the Bush Administration has finally pledged $350 million -- quite a lot of money, enough to run the war in Iraq for three or four days.

UN official Jan Engelund generated a storm of indignant huffing and puffing in the U.S. when he accused the wealthy nations of being stingy, but he wasn't even talking about the tsunami. He was talking about ongoing, everyday reality. According to The State of the World's Children, 2005, issued recently by the United Nations Children's Fund, about 29,000 children die under five every day from readily preventable causes -- diarrhea, malaria, measles -- which are almost unheard of as causes of child death in the wealthy countries. The report is a long PDF, which will take a few minutes to download at 56K, but you can read it here.

It would be feckless for me to try to summarize it in a way that would do it justice, but here is an excerpt from the summary:

• Poverty is the root cause of high rates of
child morbidity and mortality. The rights
of over 1 billion children – more than
half the children in developing countries –
are violated because they are severely
underserved of at least one of the basic
goods or services that would allow them
to survive, develop and thrive. In the
developing world more than one in three
children does not have adequate shelter,
one in five children does not have
access to safe water, and one in seven
has no access whatsoever to essential
health services. Over 16 per cent of children
under five lack adequate nutrition
and 13 per cent of all children have
never been to school.

• Armed conflict. As civil strife proliferates –
and civilians become its main causalities
– millions of children are growing up in
families and communities torn apart by
armed conflict. Many have been forced
onto the front lines. Since 1990, conflicts
have directly killed as many as 3.6 million
people; tragically, more than 45 per
cent of these are likely to have been children.
8 Hundreds of thousands of children
are caught up in armed conflict as
soldiers, are forced to become refugees
or are internally displaced, suffer sexual
violence, abuse and exploitation, or are
victims of explosive remnants of war.

• HIV/AIDS. AIDS is already the leading
cause of death worldwide for people
aged 15 to 49; in 2003 alone, 2.9 million
people died of AIDS and 4.8 million
people were newly infected with HIV.9
Over 90 per cent of people currently
living with HIV/AIDS are in developing
countries. In sub-Saharan Africa,
HIV/AIDS has led to rising child mortality
rates, sharp reductions in life expectancy
and millions of orphans.

As we discuss people in the U.S. who lack access to preventive care, the frustrations many of us experience in communicating with our physicians and interacting with the system, and the injustices and inequalities in our society that make our own health status and life expectancy worse than in other wealthy countries, we need to keep it in context. We are damned lucky, and we owe the world far more than we are giving.

The crux of the matter. . .

There is an analogy often used in public health literature, the origins of which are lost in the mist of time. Suppose there is a steep cliff in the town, and people are falling off. At the bottom of the cliff are all the caring, compassionate people who make up the medical industry. As the people hit the ground, the medical workers rush in to stanch their bleeding, set their fractures, and rush them off to the gleaming new hospital for recovery and rehabilitation.

Meanwhile, at the top of the cliff, there is no warning sign or fence. Indeed, some people are being enticed toward the cliff by people from tobacco and fast food companies and other firms, who are selling them tickets to jump off. Other people are actually in chain gangs, being driven toward the cliff by overseers with whips.
What is the sensible thing to do in this situation? Spend more on the doctors and ambulances and hospitals, so we can get to more of the people faster? Or stop squandering all that money and put up a fence?

We do the former because we depend on the market: individuals who have already fallen off the cliff will pay (or their insurers will pay) for treatment; but only society, through its government, will pay to put up a fence, and as a society we have not made this choice.

The myth that the biomedical industry holds the key to health and longevity stands in the way of creating a just and humane society. We are not just biological entities, but also social, psychological and spiritual. We are physically healthy only to the extent that we are socially healthy. Biomedicine, with its one-dimensional and mechanistic interpretation of the body, denies our very nature.

If we want a healthier society, we need to spend less on biomedicine, not more. Yes, biomedicine can cure some illnesses and reduce the symptoms of others, but it has side effects as well. I won't go through all of the harms that some people have ascribed to biomedicine -- that's for another day -- but I have identified one of the most important, and that is its opportunity cost. If we get so-called "health care" reform that appropriates an increased share of workers' income to pay for biomedicine, they will very likely be left less healthy. If we as a society have faith that the 15%+ of national wealth that we spend on biomedicine is the best possible investment in health, and if we let that share keep growing at the expense of meeting our important social needs, we will be less healthy.*

(* This passage is largely taken from a previously published work by yours truly.)