Map of life expectancy at birth from Global Education Project.

Thursday, June 21, 2012

An interesting review

As part of the New England Journal of Medicine's 200th birthday celebration, David S. Jones and colleagues review what I will summarize as the social context of medicine since the journal was founded. The mix of actual physical problems that people bring to doctors has changed considerably over that time, but so has the way in which they are classified, interpreted, and responded to.

The authors present, without much comment, the pervasiveness of racist and eugenic ideology in the profession in years gone by, particularly late 19th and early 20th Century. Also of interest are the problems of disease labeling -- which again, they present but don't discuss in any depth -- and the question of the importance of medical intervention versus social determinants and public health measures in creating population health.

For all its continued faults and limitations, medicine has gotten better over the years. Sure, there are still racist and arrogant doctors, but the normative ethics of the profession have evolved to very clearly demand respect for the worth, dignity and autonomy of every patient. Medical practice is not yet fully based in evidence and science, but it's one hell of a lot better than it was just 50 years ago. When I was in graduate school there was still a legitimate argument about whether medicine contributed more than bupkis, or maybe anything at all (viz. Ivan Illich) to the health and welfare of the population. No more. We waste a lot of money on overdiagnosis and overtreatment, but the net contribution of medical intervention to our health is huge.

And that''s why the problem of universal access is urgent. Medicine has gotten a lot more expensive, so that lots of people can't afford it; but it's also gotten a lot more worthwhile, so that denying it to people is equivalent to letting them starve or freeze to death. But, unlike food and shelter, the need for medical care that any given person has at any given moment varies radically, essentially infinitely, and generally for no fault of their own.

That is why I find it beyond outrageous that the rich, ignorant clowns that the rich, ignorant Bushes appointed to the Supreme Court are going to invent some preposterous legal rationale just to deprive a Democratic president of a policy accomplishment that Republicans supported eight years ago. If they put together 5 votes to do that, the legitimacy of the court will be destroyed along with our constitutional republic. Evil bastards.