Map of life expectancy at birth from Global Education Project.

Friday, October 27, 2006

Racism? Or Personal Responsibility?

No doubt you have heard of the studies in the new JAMA on racial disparities in health care. One, by Liu et al, is free to the struggling masses, while the other, by Trivedi and colleagues is not, but they will graciously allow you to read the abstract. One finds that in California, black patients are less likely to have complex surgical procedures done at hospitals that do a high volume of such procedures, which is known to be strongly associated with greater safety and better outcomes. The other finds that outcomes for ethnic and racial minority patients enrolled in Medicare managed care plans -- outcomes such as good control of high blood pressure, high LDL cholesterol, and diabetes -- are worse for racial and ethnic minority patients than for non-Hispanic white patients.

These studies don't give us much information about why this happens. Such disparities are very well documented and were the subject of a recent Institute of Medicine report. There isn't much that's new here. But in my view, the intense focus on disparities within health care systems is too narrow. Disparities in health begin long before people have anything to do with doctors. There are strong socioeconomic gradients in health status and longevity in every society. In the United Kingdom, after the National Health Service was established and everybody had equal access to medical care, the disparities persisted -- although throughout Europe they are less than in the U.S., because there is less inequality to begin with.

Outcomes for poor and minority patients may not be as good not only because there is something inferior about the medical care that they receive, or the interactions they have with providers, but also because people who have worse social environments are less likely to benefit as much from appropriate, or at least similar, treatment. (Equality can be construed to mean giving each person what is right for them, not giving everybody the same thing.) Of course, lack of insurance, or underinsurance, also means discontinuity of care or no appropriate care at all in many cases. It isn't easy for individual physicians to solve these problems, but it's important that they understand them, and make the effort.

While it seems obvious to most people that we ought to be concerned about such inequalities, there are those who disagree. There is a powerful strain in U.S. culture which assigns the blame for poverty to the poor. This is quite distinctive -- you don't find nearly as many people who think that way in Europe or Canada. So-called libertarians believe that measures by government intended to reduce inequality inevitably intrude on personal freedom, and deprive the well off of rewards they have justly earned.

This is an odd belief, certainly. The facts are quite evidently against it. Children are born into rich or poor families, and for the vast majority of them, that seals their fate. Nobody ever earned inherited wealth, or a daddy who could pay for an expensive private education; and no kid ever deserved to grow up with an inadequate diet in a neighborhood where it isn't safe to go outside and play. We don't get to pick our parents, or our genes, or our teachers. Anybody's career in life also depends to a considerable extent on luck, good health, good timing when first entering the job market, all sorts of factors beyond personal control. And while it is true that depriving a trust fund baby of a portion of what Daddy left behind reduces the trust fund baby's freedom, using the money to provide school lunch to poor kids or knee surgery to a construction laborer obviously increases their freedom. Greater equality means more freedom for most people, ceteris paribus, not less.

Many libertarians are under the impression that economics somehow proves that the so-called "free market" (a fiction which never has existed and never can exist) produces a just allocation of wealth, but I don't know where they get this from. There is absolutely nothing anywhere in economic theory that suggests that markets produce distributive justice. People typically work harder at low wage jobs than they do at better paying jobs. If they can't afford health insurance, and they happen to get hit by a bus or be diagnosed with breast cancer, it's not because they lack personal responsibility that they can't pay for treatment.

One person who doesn't seem to understand this is George W. Bush. His Harvard Business School professor Yoshi Tsurumi remembers him well:

Trading as usual on his father's connections, Bush entered Harvard in 1973 for a two-year program. He'd just come off what George H.W. Bush had once called his eldest son's "nomadic years" -- partying, drifting from job to job, working on political campaigns in Florida and Alabama and, most famously, apparently not showing up for duty in the Alabama National Guard. . .

In 1973, as the oil and energy crisis raged, Tsurumi led a discussion on whether government should assist retirees and other people on fixed incomes with heating costs. Bush, he recalled, "made this ridiculous statement and when I asked him to explain, he said, 'The government doesn't have to help poor people -- because they are lazy.' . . .

Bush once sneered at Tsurumi for showing the film "The Grapes of Wrath," based on John Steinbeck's novel of the Depression. "We were in a discussion of the New Deal, and he called Franklin Roosevelt's policies 'socialism.' He denounced labor unions, the Securities and Exchange Commission, Medicare, Social Security, you name it. He denounced the civil rights movement as socialism. To him, socialism and communism were the same thing. And when challenged to explain his prejudice, he could not defend his argument, either ideologically, polemically or academically." . . .

Many of Tsurumi's students came from well-connected or wealthy families, but good manners prevented them from boasting about it, the professor said. But Bush seemed unabashed about the connections that had brought him to Harvard. "The other children of the rich and famous were at least well bred to the point of realizing universal values and standards of behavior," Tsurumi said. . . .

Tsurumi's conclusion: Bush is not as dumb as his detractors allege. "He was just badly brought up, with no discipline, and no compassion," he said.

Unfortunately, people like Bush are not that hard to find in medical schools. The vast majority of medical students come from well-to-do families. Getting to medical school is far more likely for people who start out with advantages in society. And so this disease of affluence -- the sense of entitlement, the completely unearned claim to moral and social superiority -- is nearly as common in medical school as it is at Harvard Business School. While most people who enter the profession are strongly motivated by altruism and a desire to serve, many are principally motivated by the social prestige and monetary rewards. This category of doctor is likely to have contempt for social inferiors, which includes most patients.

And no matter how technically skilled, they make very bad doctors. Healing people is not like fixing cars or dairy cows. People are not just biological entities, they are biological-psychological-social entities embedded in society. Physicians need to be able to interact effectively, compassionately, and constructively with all of those dimensions. Too many of them cannot.

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