Beyond Sicko

Because this was happening a short taxi ride from the White House, I half expected someone from Dick Cheney's office to burst in at any moment, grab the microphone and proclaim the conference kaput, dissolved like an inconvenient parliament.

"I think this may be the best day of my life," Dr. Julie Gerberding, the director of the Centers for Disease Control and Prevention (CDC), said at the opening of the 2008 Leaders-to-Leaders Conference she convened the other week, along with the country's state and county public health officials. The agenda: To build a bottom-up coalition to change how America deals with health, to shift our focus from health care to healthiness and to the bigger social factors that determine our national healthiness.

Over two days, I heard so many encouraging ideas from the conference stage that didn't reflexively demonize public policy-making as nanny-statism that, well, as I said, the whole thing left me looking nervously over my shoulder for political-correctness enforcers from The Cato Institute or The Heritage Foundation.

As one speaker after another pointed out, America today ranks first among industrial nations in terms of how much we spend on health care, but last in terms of how healthy we are as a country. Pick any national metric of healthiness -- life expectancy, infant mortality, birth weight, chronic diseases incidence -- and America's comparative performance is in the cellar. It's true even when you adjust for European populations' relative homogeneity: if you only count white Americans, we are still the low man on the healthiness totem pole.

We Americans spend more than 90 percent of our health dollars on health care (on doctors, hospitals, insurance, machines, pharmaceuticals and the like), but it turns out that only 10 percent of how healthy we are as a nation is determined by what those health care dollars buy.

How can that be? What could possibly determine whether America is among the industrial world's healthiest nations, if not the thing we're all clamoring for: universal heath insurance? The answer -- and this isn't a political opinion, it's an epidemiological finding -- lies in the social determinants of our physical condition. Determinants like income, class, education, racism, the availability of public transportation, land-use policy, environmental policy, participation in the political process and a host of other factors that don't depend on our genetic makeup or our propensity to take personal responsibility for diet and exercise. Determinants that flow not from luck or individual choices, but from laws, regulations and priorities set at all levels of government and in the private sector as well. (If you want an alarming eyeful about this, check out the new California Newsreel documentary "Unnatural Causes.")

The way we currently think about health in America -- about health care, that is -- is completely understandable. We all want access to the best possible health care for our parents, our kids and ourselves, and we want it to be affordable, and we want plenty of choices. What's astonishing is that even if we covered all the uninsured's health care, we would still likely rank at the bottom of industrial countries for healthiness. The major causes of our country's healthiness or unhealthiness are all upstream of the things that send us to doctors and hospitals and pharmacies. The causes are poverty, and stress, and the amount of control and autonomy we have at our jobs, and whether there are showers there, and what they put in the vending machines. The causes are access to early childhood education, and to day care, and whether schools are built near asthma-breeding freeways. They are whether your neighborhood offers public libraries and public transportation and walking trails, or public dumps and liquor stores and fast food franchises.

"I had a colonoscopy the other week," the CDC's Dr. Gerberding told the 400 public health officials, business leaders and nonprofits she was hoping would sign on to a "healthiest nation alliance." "Actually," she added, "I was billed for two colonoscopies, though I'm sure I only had one."

Clearly she's not unaware of the madness of our present health care system. No one facing a family medical crisis wants anything but the best possible treatment at that moment. No one should lack access to quality health care. But prevention is even more important to the country as a whole than treatment is, and the free market alone hasn't and won't deliver the level of prevention we need.

To me, the underlying reason America has fallen so far behind in the healthiest nation race is the exhausted dogmas that have dominated public discourse for something like 30 years -- Horatio Algerism, social Darwinism, the magic of the marketplace, deregulation is good, government is bad, pull yourself up by your own bootstraps and devil take the hindmost.

We now know what America looks like when those kinds of ideas rule, and not only in the health sector. I'm glad that, at long last, public officials are finding their voice to express politically transgressive thoughts, like the idea that income inequity and racism are bad for America's healthiness.

I just hope that the Ayn Rand Society doesn't get on their case.

This column first appeared in The Jewish Journal. If you'd rather read about Angelina Jolie's ob-gyn than find my other JJ columns, click here.

Comments

[dragonsmusic]

I enjoyed this article. I would like to add that reading Natural Cure's They Don't Want You to Know About by Kevn Trudeau will give you an even deeper insight as to the reason why Amercians are so sick.

[stopbeingSMUG]

"I am going to give health insurance to 47 million Americans who are now without coverage." Obama
That 47 million statistic includes illegal immigrants - who virtually all lack insurance. In fact, about one in four of those lacking insurance is here illegally. Would that encourage more folks to enter America illicitly.?

About 15 million of the remaining uninsured are eligible for Medicaid but haven"t signed up - mainly because they haven"t gotten sick. (or they spend it on some item that isn't a necessity-I-phone) When they do, they enroll in Medicaid and we pick up the full tab for their health care relatively cheaply.

The rest of the uninsured pool? Virtually all the children are eligible for the State Children"s Health Insurance Program. Some aren"t enrolled because the parents haven"t bothered, but most are eligible. That leaves about 20 million uninsured adults who are US citizens or legal immigrants. There are far better ways to handle their needs than to turn our entire health-care system upside down.

Bureaucrats deciding who gets to see an oncologist, who can have an MRI - and even who can have bypass surgery and who"d die for lack of it. I don't want my father waiting weeks to have another bypass surgery. Just not right!!!

[squander123]

Just for information purposes, I'm lucky enough to live in a country which has free health-care for everyone. And it's not bureaucrats who "decide who gets to see an oncologist, who can have an MRI". You feel ill, go to the doctor, if they think you need to see a specialist they send you to one, and that specialist decides - on medical grounds alone - what tests or treatments you might need. It's very simple. No paperwork, no bills, and no bureaucrat to be seen.

One of the results of this system (and this isn't exactly rocket-science) is that people do seek medical treatment early when they feel ill, and therefore most minor complaints are sorted out before they become serious. One of the HUGE issues for the US system of health-care, it's always seemed to me, is that minor medical conditions can become quite serious or even untreatable if they're left untreated for a long time: and that's exactly what's bound to happen when visiting a doctor is a major financial decision for a significant proportion of the population. So then - surprise, surprise - you have a 'generally unhealthy' poorer population. Madness.

[YankeeCanuck]

Is it better to have an insurance company raking in the money, paying its CEO multimillions each year,hiring a fleet of MDs (who have never seen your father) to decide whether or not he gets treatment?
Keep in mind that these corporations take no risk, but profit hugely.

[verhaftik]

And what is worse for us researchers? There are no "cures" for diseases being funded. That is an internal AMA/Pharma No-No. Just "drugs/therapies/surgeries/interventions" to mask and/or manage symptoms. Thus, innovation, for things like preventing DM I or Alzheimers won't ever happen in the US. Not under this system. Too profitable to make "treatments" to manage the disease. But cure the patient? Heavens, no!

Don't be fooled. Healthcare and medical research is the biggest scam there ever was. The capitalism mantra - competition will lead to efficiency - fails when it comes to healing people. Those concepts cannot co-exits because curing people annihilates the healthcare consumer. Hence, such is the system we have today.

The real reason the doctor (Pharma, Ins Co. nurse) smiles when they see your fat and / or smoking / pill popping self? $Money$.

[verhaftik]

This is easy. Ranking dead last in health. But ranking # 1 in healthcare megaindustry profits!! They are inversely related, see?

It's fundamental. It's just the AMA / physicians/ Pharma pretend that our health is what is important. Truth: only their pocketbooks are important. How will the healthcare megaindustry hope to be profitable if all their patients are healthy?

Vytorin, Vioxx, etc are essentially failures. No diabetes medication works as good or better than diet & exercise alone. NONE. (Look at any proprietary piece and see that holds true.) We dump money into this industry that enables and encourages us to be *unhealthy for a long, long time* (= a longer lifespan to be medicated, or at least the industry hopes).

If the medical field wanted us healthy they'd harangue us nightly with "get off the couch, you fat sh*t!" messages. But, instead we see fat people popping pills and reading their insulin meters. The US "health" industry is not about wellness, pure and simple.

[YankeeCanuck]

Well, you've got that right!

[rcat99]

Part 1
The basic insurance model makes a lot of sense. All those vulnerable to a threat chip in a manageable amount to the general fund and the relatively few unfortunates who become actual victims of the negative event are able to use the resources of the fund for their recovery. Good plan; it's social, moral, responsible.

But why is there so much dissatisfaction with health insurance today? Where does the model go wrong? We already spend more than any other country in the world on health insurance and yet our whole population, unlike those other countries, is not even covered. Our life expectancy, infant mortality, access to medical care and general healthiness lag those countries shelling out less. What gives?

[balthus]

The most important point Marty is making - and it seems by their comments many posters are missing - is that health care should not be seen as something separate and isolated from the rest of our lives. In the U.S., most people live paycheck to paycheck (or close to) and the consequence of losing their job is the frightening (and often real) likelihood that they will lose their home, their car, their status in the community, and their healthcare. Under such conditions, how can we expect people to maintain the positive mental, spiritual and physical balance that is essential for wellness?

What we need is a system in which people don't have to live in fear of job loss, and where the pitfalls we all face at one time or another are shared by our community, which will help see us through to new opportunities.

[rcat99]

Part 2
Could be the middle man? The pot-holders. Those whose responsibility and role is to collect, monitor and maintain that fund whose extensible reason for being is to provide the relief to those who have chipped in and then suffered a loss. Now it's an important role, that of administration, and there's obviously a cost associated with executing the function.

But should that essential but primarily clerical activity be so generously compensated that the pot-holder earns Croesus-like profits for merely maintaining the fund and keeping records? Perhaps there's a better way.

All those bureaucrats we hear about taking up space in our big bad government offices perhaps could be put to work performing this task. They can count and maintain files and being free-loading government workers they would be utterly lacking any hint of the profit motive and hence be kept satisfied with the usual meager government compensation. No multi-million dollar salaries, expense accounts, shareholder dividends and capital gains to be pumped up. No need to invest the fund holdings in risky ventures to show big gains to Wall St. Just plain old, dull prudent investing and dreary accounting. Boring, but efficient and more cost-effective. Maybe we could even cover our whole population and start getting our money's worth instead of feeding the already too well fed.

Social, moral, responsible.

[SEQUOIABISON]

It all begins in the early ages when we raise our children to become doctors, not to help humanity but because it is a sure fire way of getting rich.

When we made healthcare a for profit business it became a lost cause right from the start. The profit motivation corrupts a true analysis of the patient's condition. If a doctor has lots of bills to pay plus alimony and child support he may choose to perform unnecessary surgery or call for unneeded medical procedures just to bring in money?

We need to take the profit motive out of healthcare and start treating people like we care about their health and not their money.

[hiprogloho]

What about damn lies and liars behind the statistics? When you say "we", you don't mean We The People, do you?

"We're" not represented. Folks who buy and sell opinions in the media and rig elections are the real culprits. The top 1 percenters perhaps. We are just sheepish victims.

"They" with the money and power to change the world would rather fix elections, start wars, sell the environment to black gold and give themselves tax breaks.

As the US falls to ruin, try to live outside a gated community in a country that is fast losing its soverignty to economic outsourcing and illegal immigration.

The land of the naive and the home of the knave that once saved the world from Hitler and Communism has in the last decade fallen prey to the evil it once conquered.

So We is an oxymoronic term as we confront the surreality of our end days. There is no we in the downfall of America. There is only a They.

After they sell us to the rich money power and fend off havenots with toxic media, food and drugs or propaganda, bullets and bombs, their evil has already been naturally selected by those who fight the battle of civilization with love, sex and babies.

One day selfishness and greed will be against the law like hate and violence is. But by then it will be too late. For WE will be outnumbered and THEY will have chosen their "Rosebuds" over OUR rose gardens.

[youngec]

Everyone is blaming health insurance companies for our health care crisis. Rightly so, but improvements will never be made unless the pharmaceutical companies, who are the biggest profiteers of the current system, are reined in. These companies are not in the business of making us well but keeping us dependent on their products. They are marketers mostly. They spend more on marketing than on research. Side effects, sometimes deadly, are just the cost of doing business.

[HansB]

To be fair, let's admit one reason US health care is more expensive: you Americans with your fractured system pay for pharma research, we Europeans with our single-payer systems have negotiated much lower prices with the industry. If you switch to single-payer, likely the rest of the world will have to contribute its share to research.

Or to be more succint: you Americans are the suckers paying the research bill for everyone, because you are the only ones to insist that negotiating with pharma must be done from a position of weakness.

[RN4MERCY]

Greed, rather than high R&D costs, is the main reason for high prescription drug prices for brand-name drugs in the United States.

[ProudNeoCon]

So let me get it straight: Health care itself is not a problem. the problem is "income inequality" . So if start paying people the same - everyone will be healthy?

No thank you. I have already lived in USSR before - no desire to see USA turning into the same.

Nationalised health care = rationed health care. There is no magic wand... So the question is not if you want a godd healthcare for eveyone, but would you rather have good healthcare for some and no healthcare for others or mediocre healthcare for everyone...

[laocoon]

Our current system = rationed health care. the rationing is just based now on money and insurance coverage. what do you call it when it is impossible to get a growth biopsied? you would prefer money(insurance) to determine the rationing rather than nature of the illness and need for prompt attention. Better others die than I have to wait for nonemergency procedures.

[ProudNeoCon]

Yes, I would prefer my choice to ration my healthcare rather than goverment. When I choose a job I selected one with better healthplan not with better salary. I put my health before other needs. Therefore I should get better healthcare than people who spend that money on something else...

[HansB]

"Nationalised health care = rationed health care". Like every other neocon opinion I have ever heard or seen, that is ideology, not fact. You may WANT it to be that way, that doesn't mean it is. I live in France and my health care is not rationed in any way, and it is certainly not mediocre either.

[ProudNeoCon]

It is a fact. The only way to control the cost of goverement run healthcare is to deny healthcare above certain level. That level could be quality or access. I have not lived in France so can not argue with it. However, I have experience with Russian, British, German and Canadian healthcare system and they are clearly rationed. Try getting a dentist appointment in London or MRI in Montreal...

[vippy]

typical neo-con answer! How about the best there is for the U.S. After all we have been brainwashed for a decade that we are the best! Now let us see it in all facets of our life.
Russia is coming along well, wished we had their tax system and GDP. It still has some
growing pains but we have bottomed out.

[ProudNeoCon]

Unlike you I have been in russia - you are welcome to it...

[ScaryTruth]

The game is rigged. And the real ruling class cowards that hide behind the curtain benefit from the health care staus quo in America. Our current quagmire of disfunction that perverts common sense is no accident.
Each time a discussion in our marbled halls about health care matters takes place, question your Senator/Representative from which medical interest's trough he/she's feeding from.
Each time an expert health care commentator appears on your tube in the perpetual struggle for your mind, question the cost of their loyalty - and whom is paying for it.

[dutt]

A compassionate conservative would say you Americans are a bunch of malingering whiners and probably suggest you try prayer.

[ChicoDavidRN]

Everything works as a system related to our health and healthcare.
When a society is run on the basis that profit is the highest goal, you get the food that is most profitable, not the food that's best for you. Etc.
Oher related thoughts: Americans sue for malpractice more than in other places. You can debate the causes and effects of that - I know from my position as a nurse that only a small percentage of the people harmed by their caregivers sue - but think about the underlying reason for it. Is there something in our national character that makes us litigious? No - it's because if you are injured by a doctor or a defective product, and can't work, your only hope of economic survival is to find someone at fault and sue their ass. In most European countries it's handled in a no-fault fashion - you're injured, you get the care you need because you need it, not because someone was at fault.
It's often pointed out that doctors in many other countries make less than ours. and that's true, but they still live very nice upper-middle class lives. And they CAN make less, since they don't start their carreers with giant student loans and they know they won't have to spend a fortune to educate their kids and they aren't spending hours at the end of every work day fighting with insurance companies trying to get care authorised or get paid for what they have

[Deane Waldman - Huffpost Blogger]

Marty,

The massive regulatory and legal structure that oversees health care, of which CDC and OHRP (Office for Human Research Protection) are parts, is intended to protect us. It does the opposite.

Read my post [www.thesystemmd.com/?p=11] recounting how OHRP shut down a life-saving, cost-reducing program in Michigan solely because it did not follow their rules! Rule-following is more important than our safety, our health and our dollars.

As I wrote in "Curing Sicko" here (Huffington Post, July 1, 2008), WE must first agree on what is wrong. The "we" in that sentence and the next sentence refers to the general public, not the policy wonks who tried to give us ClintonCare or the conferees gathered at the 2008 Leader-to-Leaders Conference. After we agree on what is wrong, WE must decide on what we want a new system to do.

As you wrote, we are plagued with "exhausted dogmas." (I really like that phrase.) They dominate our public discourse and become accepted because the politicians say them over and over while self-styled experts nod their heads.

There is no quick fix. The experts do not have the answers " only we the Public do. The "conference" we need is a national dialogue about healthcare among the populace, not self-styled experts talking to other self-styled experts.

Ayn Rand would be nauseous if she saw what we call our healthcare "system."

Deane Waldman, MD MBA
System MD