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.

Follow Marty Kaplan on Twitter: www.twitter.com/martykaplan

Comments

[mommamia526]

Just take a look inside school buildings, and sniff and smell. Often not a healthy environment. Look at infrastructure, buildings and streets, and see how well, or not, the environment is maintained. Forced air inside uilding with ducts that are never cleaned and filters that are hardly ever changed out! People and kids work, all hours, because the one thing important to all is numbers, especially dollar scores. It does not mean much, if it is not backed by a healthy and strong society and economy. They sit and stand for hours. There are no sidewalks to speak of, and if there were, people are not walking. They do not even do much *walking* in shopping malls.

Stress. Yes, if I go by my kids and grandkids, children work all hours and somehow try to fit school in, somewhere. Schoolwork and learning is hard work, it is not only intellectual, it is physical as well. My youngest grandchild has been working, full time, and the last few years time and a half, while still maintaining a full load in school and making excellent grades. This summer she quit one of her jobs. She was tired of sitting all day. She has replaced that job with a job as a landscaper, sothat she gets to be outside, and is no longer cooped up all day. More importantly, she does not have to sit all day.

[thejazz]

Compared to Canada, the U.S. healthcare insurance thing is a complete pain in the ass. I've used both, and can afford the one in the U.S. Same care, huge pain for the U.S.

[drricklippin]

Marty-

Thanks for keeping Health Care Reform in the news while Obama is overseas.

Yes- the excesses of "the free market solves all" philospohy as applied to health care is finally coming home to roost as we witness the real time collapse of our US health care system.

Yet ,you will hear jingoistic phrases like "socialized medicine" from Mr McCain and his surrogates.

Another belief I personally hold which is shared bt NIH Chief Elias Zerhouni and former GAO Chief David Walker is that a high-tech-high-cost treatment based "disease care system " IS NOT ECONOMICALLY SUSTAINABLE.

Prevention- both individual(health behaviors)and institutional (public health) needs to be a priority for a true sustainable health care system in this nation and abroad.

Dr. Rick Lippin
Southampton, Pa

[gvc]

Studying the social determinants of health is:

- social
- scientific
- intellectual

In other words, Unamerican.

[cunuck]

Sad but very true..........

[mommamia526]

I started commenting on blogs about healthcare in the U.S. because of the desasperation of a surgeon who had treated me. Shortlly thereafter he started action by trying to get doctors together to influence legislation. One issue is Medical Malpractice Insurance, but the most important issue to him was patient access. He said: "if a patient needs a doctor, he needs to be able to SEE that doctor".

Mr. Kaplan is right. It is access to doctors and medical care. It is the idea that "bei uns zu Haus ist alles besser" - here at home everything is better - as the Germans used to say. It is preventive health and dental care and nutritional supervision for babies. It is school nurses and doctors' visits. It is also healthy building, which are well kept and clean, up to date and modern, especially schools.

Sloganeering about healthcare and the best medical care does not make it so. My (ex) husband was a *board certified* and practicing physician in Europe and in the U.S. and I was a patient on two continents. In Europe he only spoke about his patients. In the U.S. patients are still important, but even more important is his (financial) status, and especially is this the case to his third wife. Money is important to Americans, and so is dominance over another. But, as being a doctor goes, my ex husband was the same doctor he was in Europe as he was in the U.S.

[DanBest]

Medicare overhead costs run about 3%, whereas the average insurance program runs 12 to 15%. The US taxpayer actually subsidizes the insurance companies so that they can compete with Medicare. Where does all that extra money go? I can assure where it doesn't go. It doesn't go to pay for medical expenses. It goes to pay the overbloated salaries of the executives that run these companies. Every extra dollar they take out of the system represents a claim that will not be paid. But, hey, they get to live the high life so that counts for something. Doesn't it?

[paixa3]

Great poste, thank you.

[rbspickles]

Our esteemed, beloved politicians have excellent healthcare. They see no need to change a thing so why should they?

[TexasDem0]

Complex social issues do not have simple answers, but this is the exception.
Health care is operated as a profit center, driven by corporate greed and shameful corporate ethics.
We need health care to focus on health care.

[Rog49Thomas]

It's just like guns. I'd expect someone from Tejas to understand.

When health care is socialized, only socialists will have health care.

[babylonandon]

Why is it that when America gets compared to another nation it is always some country with a tiny fraction of our population and a relatively homogenous and employed population?

Lets face it. Canada is a phenominally wealthy nation with a very small population, vast resources, and virtually none of the same sorts of poverty and illegal immigration issues that cost us soo much money. Same for Australia, Norway, Sweden, etc.

England, with a much higher population density, poverty, and immigration issues has real problems with its healthcare especially in regards to non-emergency care. Folks who can afford it leave the country to pay for stuff getting fixed.

If France was sooo healthy then why did over 13,000 seniors perish during a summer heat wave a couple of years ago? Doesn't seem like they had any resources or anyone watching them. If that happened here there'd be such an outcry you'd hear it on Mars!!

We have over 300 MILLION people in the bad old USA. You want to compare us to our actual peers and you'd do better to compare us to India, China, Indonesia, and Mexico...they are our real peers in this area.

The only large population county we do look bad next to is Japan and again they have a racially homogenous population with a high work ethic so their people pay their way in life (there aren't a lot of freeloaders in Japan!).

[cunuck]

You need to educate yourself. You can start with this PDF document.

Congressional Research Service
U.S. Health Care Spending: Comparison with Other OECD Countries
September 17, 2007
http://digitalcommons.ilr.cornell.edu/cgi/viewcontent.cgi?article=1316&context=key_workplace

Summary
The United States spends more money on health care than any other country in
the Organization for Economic Cooperation and Development (OECD). The OECD
consists of 30 democracies, most of which are considered the most economically
advanced countries in the world..
However, research comparing the quality of care has not found the United States
to be superior overall. Nor does the U.S. population have substantially better access
to health care resources, even putting aside the issue of the uninsured.

[Rog49Thomas]

How dare you disabuse us of some of our most cherished delusions.

I'll bet you've never been to Canada, England, France or Germany - where they have forms of universal health care.

Well, I have and can tell you it's not a pretty sight.

Broken people suffering under the shackles of socialist medicine. You can hear the chains move when they walk and see the dispirited lifeless looks in their eyes. All of them with a burning desire to come to our great country and have to struggle to afford medical care.

How sad!

[justmeinAz]

Oh, I didn't realize that America was just crawling out of 3rd world status like the rest of these countries you mentioned as our peers. That's good to know. I guess when I learned about our industrial revolution in history class, we were actually discussing current events and I didn't realize it. Thank you for that lucid clarification. Now we can finally get to the bottom of this issue. America's health care is better than Mexico's! Go team!

[Rog49Thomas]

USA#1

[cadsuch]

The freeloaders are the people who take my insurance primium money and build buildings with the name of the insurance company up on the 35th floor. The building is fully staffed with paper shufflers whose only job is to deny care. The paper shufflers are taking premiums from people and they are STILL deying care.

Don't tell ME about work ethic. The only ethical problem we have in THIS country is managerial!

[cidelson]

Nice try blaming the abysmal failure of our healthcare system on poor people, immigrants, and density. Perhaps you're unaware that France, Britain, Germany, Canada and other industrialized countries which all have better patient outcomes than the U.S. also have immigrants and poor people. And want to see density? Japan, which is about the same size as California, has more than three and half times the population of California.

Comparing the U.S. to other industrial countries is exactly the appropriate comparison, the very reason research organizations use that barometer. Such as the Commonwealth Fund which just reported that among industrial nations, the U.S. ranks last in preventable deaths despite spending twice as much per person as anyone else.

And you want long waits? The study showed that less than half of U.S. adults get a timely appointment with a doctor when they are sick, and are less likely to get after hours care unless going to an emergency room.

Why are we different, all the others have a national or single payer health care system, and we don't. All the others allow private insurance companies to control the health of their people, and we don't.

[cheshirecat831]

Someone seriously needs to address the diseases which are actually side effects from the drugs Big Pharma is pushing on all of us. Statins are a case in point. I suspect the interest in getting them certified for over the counter sale and the idea of giving them to children may be because of the number of people taking themselves off of them so they can feel better. Elevated cholesterol levels are better than the side effects.

[Wilburrr]

It seems that immigration would depress these numbers to some degree, but the level of care available in the U.S. varies dramatically based on income. There is a movement by nurse practitioners to make the same level of medical treatment available to everyone in the U.S. that is available to Dick Cheney. It is called "Cheney Care" and a simple web search will yield bountiful results.

[Paul]

This is the end result of the "Reagan Revolution."

Just when the most successful societies have moved toward increasing government participation, conservatives have sold the idea that big government is bad.

Well, we lose.

[werbenjagermanjensen]

Last time I was at the hair salon the stylists were taking up a collection for a coworker whose baby was recently diagnosed with leukemia (it also has Down syndrome.) Is this our future? Are we supposed to have bake sales or persuade some business to put a donation can by the cash register every time somebody in our family gets sick?

[paixa3]

Clearly blame congress again on this. There are no restrictions (the best that I can tell) for insurance companies to own parts of phara, HMO and medical related industries and visa versa. Add to that, pharma brainwashing an owning doctors and voila, you have one big greedy mess.

[KillTheMessenger]

And Congress is elected... by the people. There you go. Now we are up to something. Once the voters get their priorities right, we will have a working government.

[hjfraser2002]

Well lets go once step deeper. Lets work on getting people getting the right information to vote for what is best for them. There is so much misinformation being put out by the parties and MSM, most people can't make the right descion.

[rubinoff]

I agree witcha...I'm old enough to remember when advertising on televison was about cereals, detergents, toothpaste, etc., now,;however, mostly of what one sees is advertisement of one drug after another, not to mention all of the 'side effect,' which sound worst than the original disease. Would this be called 'legalized drug pushing?'....One could cry on a daily basis, just by looking at this 'mess.'....and, yes, it's all about 'greed.'

[demright]

It's the corporate bottom line.

[lafrance]

This country no longer works. there is something obscene about spending so much money for underquality care.
But, we also rank low in education (what do you expect from a country that is so proud of being anti intellectual), science, ect.
we can always proudly exclaim we are last. we are last.

[paixa3]

I would like to know the education ranking......37?

[Rumplestiltskin]

but we spend more than most other developed countries on education. Imagine that.