Sunday, June 10, 2018

Why don't we spend more on public health? It is harder to see the bullets we dodged -- and then there is profit.

It Saves Lives. It Can Save Money. So Why Aren’t We Spending More on Public Health?”  (New York Times, May 28, 2018). Actually, this is a terrific question. As so often, it is complicated. Let’s start with the benefits that authors Aaron E. Carroll and Austin Frakt describe. First, there are vaccines. They eliminated smallpox and virtually eliminated polio in the United States. They have dramatically reduced the rate of common childhood illnesses including measles, mumps, rubella, chicken pox, and Hemophilus influenza (H. flu) infection. They have the potential for essentially wiping out cervical cancer through immunization against HPV, and liver cancer (as well as many forms of chronic hepatitis and cirrhosis) through vaccines against Hepatitis B.

A huge public health intervention is making our environment safer. This means having good sewage and clean water, and lead-free gasoline and cleaner air. These changes have saved far more lives, and improved health much more, than all of the individual medical care interventions combined. If you have traveled abroad, especially to less developed countries, you know how important these are. Indeed, better sanitation, as well as better surveillance and treatment, have dramatically reduced other infectious diseases that were once terribly feared, notably tuberculosis. And inspection of our food supply, restaurant and otherwise, are another very important part of public health.

The other big public health measure is education. Of course, education can be and is provided to individuals by health professionals as well as populations via public service education, but it is major nationwide public health efforts that have made a big difference. These include the huge decrease in cigarette smoking, and the greater safety of automobiles and their exhausts. Cigarette smoking used to be ubiquitous (see any WW2 movie) and in what would shock young Americans today, widely practiced in restaurants and even college lecture halls. Today that is unimaginable, and smoking in most places is aberrant, with less than 15% of adults currently smoking and most of those trying to quit. Car accidents are still a major cause of death and injury, but deaths from cars are way down. Almost none of this is related to people driving more safely and almost all of it to safer design of cars (think seat belts, air bags, engines that collapse down instead of back in a collision) and roads. Lead poisoning of children is way down in most places in the US thanks to lead being banned from gasoline and paint.

There are still many challenges on the public health front. Reducing the rate of chronic diseases though education around eating huge numbers of empty calories still have a long way to go. The terrible infectious disease epidemic of recent decades, HIV, has been greatly reduced by treatment, but until there is a vaccine, high-risk sexual behaviors persist. The opioid epidemic is killing more and more people, and it is only through societal approaches that this is going to be reduced.

The epidemic of gun death is not abating; many studies and articles in the press have recently discussed the increase in the suicide rate, often prompted by recent high-profile suicides such as those of Kate Spade and Anthony Bourdain (How Suicide Quietly Morphed Into a Public Health Crisis; 5 Takeaways on America’s Increasing Suicide Rate, ). While neither Spade or Bourdain used a gun, guns are the cause of death in at least half of suicides, and suicide far exceeds homicide in terms of numbers of gun deaths. Those who believe it is not the availability of guns that causes deaths from both causes, and other methods could be used to kill oneself or others, are simply wrong. Easy availability of guns, far more effective and efficient at killing oneself or others than any other method, absolutely has been demonstrated to increase both homicide and suicide. Suicide by gun is over 90% effective; by drugs less than 5%. “Successful” suicide rates are far higher in high gun states (e.g., Montana) than in low-gun states (e.g., Massachusetts). Homicides are also more common where guns are at hand. And, in regard to school and other mass shootings, while you can kill someone with a knife or a baseball bat, but it is hard to commit mass murder with them.

So, why do we not spend more on public health? Why do we spend so much more on what is, from a societal point of view, much less effective individual health interventions, and less than 5% of that on public health? One reason, of course, is that when each of us is sick, we (usually) want treatment, as much as possible, especially if there is a chance that it could cure us, or at least ease our suffering. This is understandable, and it is tied to the fact that we have much greater awareness of treatment of something ailing us (curing our infection, relieving our pain) than of not having disease because of the presence of public health practices. As I would tell students, how often do we wake up thankful that we do not have cholera because we have a clean water supply? Indeed, when we find that the water in Flint, MI, is contaminated with lead, we are shocked because we assume our water is safe; when we find an E. coli outbreak from a restaurant, we are shocked because we assume our food is safe.

There is also, unsurprisingly, the issue of the money that to be made. The provision of public health is rarely a big profit center, and it is usually, therefore, done by government – local, state, and federal. Individual health care, however, is a huge money-maker for insurance companies, hospitals, doctors, pharmaceutical and device manufacturers, nursing home companies, and on and on. All that money – over $3.3 TRILLION by recent estimate -- spent on your and other individuals, while it may (or may not) have a salubrious impact on you, is going into someone’s pocket. On the flip side, public health interventions often reduce profit, especially when they are very effective. The struggle against tobacco, which killed more people than any other cause by far, was fought long and hard by the tobacco companies (currently now plying their wares in the less-developed world).Each of the changes to cars that led to the great increases in safety was fought by the industry. Today, we continue to see tremendous opposition to rules that make our environment (air, water) clean and safe; sadly, under the current administration, many of these rules are being rolled back, which will absolutely decrease our society’s health.

I guess I also need to address the people who believe that vaccines are unsafe. They are a major threat, and presumably haven’t seen children dying of measles, of the suffering of chicken pox and mumps, of the morbidity from H. flu infections of the middle ear (my students have never seen it!) or deaths from H. flu epiglottitis. Yes, there can be minor side effects from some vaccines, but the benefit is overwhelming.

Finally, as always finally, it is the poor and disenfranchised who suffer the worst. While sometimes we have the perverse satisfaction of outbreaks of vaccine-preventable diseases in well-to-do communities, anti-vaxxers unconscionably campaign in immigrant/refugee communities telling people to not vaccinate their children. The poor and minority city of Flint suffers a poisoned water supply. The oldest, cheapest houses are likeliest to have peeling lead paint and be located near polluting factories and dumps. Tobacco and junk food manufacturers advertise most heavily in minority neighborhoods. And, of course, the murder rate is highest in poor and minority communities.

Good medical care for individuals is valuable when it is needed, and could be less expensive. Public health measures are even more valuable and cost-effective. We need to increase the money and effort spent upon public health interventions, and certainly not scale them back.

Benjamin Franklin said an ounce of prevention is worth a pound of cure. It’s true, and is a great argument for greater investment in public health.

Saturday, June 2, 2018

The Administration's New Proposal to Address the Determinants of Health

  (a Shakespearean sonnet)

Together, many things affect our health,
Genetics and environment to start,
Where we live and whether we have wealth,
Our personal behaviors play a part.

The Trumpers say they want us to act smart,
Not to smoke, or drink too much, let’s say,
Or overeat (it might affect our heart),
Or else – they’ll take our Medicaid away.

Then we won’t have access to healthcare,
Or treatment options when we do get sick.
Clearly, this is totally unfair,
To solve the problem, it won’t do the trick.

To have a healthier society,
We need real reform, not smug piety.


Saturday, May 26, 2018

Maternal mortality in the US and UK: Why do we tolerate paying so much more for so much worse outcomes?

Last year, ProPublica, in association with NPR, published Why Giving Birth Is Safer in Britain Than in the U.S. In typical journalistic style, it starts by grabbing your attention with a case report of a woman in England who almost died of post-partum hemorrhage, but did not. The lesson is presumably that she did not because the physicians, midwives, and others attending her followed a rigorous set of established protocols for addressing post-partum hemorrhage that are implemented nationally in the UK.

Of course, there is a possibility that this individual woman could have died, or had to undergo more invasive surgical procedures further down the protocol’s algorithm, but the real point is that, overall, the system is working. The evidence is in that the maternal mortality rate (deaths/100,000 women delivering) is 8.9 in Britain, while in the US the rate in 2015 was 25.1, three times that of the UK! What makes this more dramatic is that the disparity has developed only since 1990; until then the maternal mortality rates in the US and UK had been declining in parallel since the 1950s.

The article cites several reasons for this difference. One, a very important one, is that the UK collects data on maternal mortality nationally and develops guidelines based upon this data which are implemented nationally. In contrast, the US collects data at best by state, or even by hospital, and
There is no federal-level scrutiny of maternal deaths, and only 26 states have an established committee (of varying methodology and rigor) to review them. Nor do all U.S. hospitals routinely examine whether a death could have been avoided. Procedures for treating complications such as preeclampsia, and for responding to emergencies such as hemorrhage, vary from one doctor, hospital and state to the next.
This is true despite the fact that the methods used by the British to collect and analyze this data were developed in the US. While there has been a well-documented 30-year effort to improve quality and to reduce preventable deaths (a category into which most maternal mortality falls) in the US, led by such organizations as the Institute for Healthcare Improvement (IHI) and embraced by such other organizations as the American Hospital Association (AHA), National Center for Quality Assurance (NCQA), the Joint Commission for the Accreditation of Healthcare Organizations (TJC), the National Academy of Medicine, and on and on, no compulsory national approach to this problem has developed. This reflects a common, and often knee-jerk, opposition to centralized approaches to almost everything, even when they have been determined to have an important effect on reducing death. It is actually parallel to efforts within hospitals to standardize care, to require, for example, all surgeries to go through a series of prescribed steps (“timeouts”) before operating, or limiting the number of different devices implanted to those needed by different types of patients rather than by the preference of the individual surgeon (for an interesting discussion, see A. Gawande, “Big Med”, New Yorker, August 13, 2012). That is, it is effective where it has been done, but it is not mandated to be done everywhere and comprehensive national data is not even collected.

Another big part of the successful UK approach to the reduction of maternal mortality has been collecting detail on what happened and why; this goes beyond “there was a death”, or “there was a death from hemorrhage”, or “there was a death from sepsis”, to identifying why it happened, particularly if the reason was something that is relatively easily addressed. Marian Knight, head of MBRRACE-UK, the group that collects the data and makes the guidelines, says
It’s all very well to know a woman died of sepsis, but to know that she died of sepsis because nobody measured her temperature, as they had no thermometers on the postnatal ward, that’s where the instruction Put a thermometer on your postnatal ward might make a difference. It’s not just the what, it’s the why.
Can you believe that there might be post-partum units where there is no thermometer? Apparently it has happened. And having a rule that it must be present is a way of preventing it from happening again.

There are at least three other important dimensions. One is that, as the report states, “These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy.”  This is not a big surprise.  Poor women, minority women, rural women, and uninsured women do much worse, and are much more likely to die from complications of delivery. It is the familiar song in the US, as in so many areas, of health and of every aspect of society. Is it not true in Britain? The article goes on to say
In the U.K., while inequalities persist when it comes to serious complications, according to 2012-2014 data, there is no statistically significant difference in mortality rates between women in the highest and lowest socioeconomic groups. All British women have equal access to public medical services, including free care and prescriptions from pregnancy through the postpartum period.

This also has two components; the greater equity of the quality of healthcare delivered to all segments of the population, a result of having a national health care system, and less disparity in the “social determinants of health”, the actual quality of the lives of people (women, in this case) before they access care. Especially for rural women, some of the problem the lack of an adequate number of health professionals. Over 20 years ago, family medicine residencies in Texas were surveyed and only a small percent of residents were interested in providing rural obstetric care, but no OB/Gyn residents were! This has not improved; while a recent study published by Tong, et al., in Family Medicine (Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care) found that 22% of FM residents planned to deliver babies, they cite his 2012 study that showed that only 9.1% of FM residency graduates were delivering babies 1-10 years out into practice despite an intention to do so of 24%, comparable to the current study.

Another dimension is that the difference in maternal mortality reflects a greater focus on the health – and life -- of the pregnant woman in Britain, while in the US the focus is more on the health of the fetus and the newborn. This goes far beyond the issue of abortion, although the focus on children rather than women is one that is also characteristic of the anti-choice movement in the US. It is so deeply ingrained in our culture that even many health professionals (including midwives, doctors, and nurses) who see themselves as “pro-choice” and would never want to see a maternal mortality, are still more focused on the fetus and baby. It results in a practice, if not a belief, that considers the woman but a vehicle for producing a child.

Finally, there is cost, ironically but again unsurprisingly much higher in the US. Much higher. The total cost for a normal vaginal delivery in the US is about $30,000, and about $50,000 for a Caesarean section. In Britain, the cost for a normal vaginal delivery or planned Caesarean is about $2500, or less than 1/10th the cost in the US, perhaps rising to $3400 for complicated cases (such as the one that leads off the article). Thus, the US charges far more, but has much worse outcomes for maternal mortality (as for many other conditions). This is not a side note; it is not just an interesting contradiction that our care costs more but has worse outcomes. And it is not by any means limited to pregnancy care or maternal mortality, but is present in our healthcare system at almost all levels and for most conditions. What ties these two components, cost and quality, tightly and inversely together, is that our “healthcare system” is only secondarily about delivering quality healthcare, and primarily about being a profit-making business.

So, that is the bottom line. The US has three times the maternal mortality rate of the UK despite charging ten times as much for delivery. The reasons are the absence of a national strategy to identify and remedy the causes of maternal mortality and the lack of a national healthcare system to provide the access necessary for women at risk. It causes the suffering and death to disproportionately affect those women who are already at greatest risk: the poor, minority, rural, and uninsured. The root cause is that our healthcare system is composed of poorly interconnected components, most of which are run as businesses to make money.

It is inequitable, and it is irrational from a health perspective if not from a business one. It causes unnecessary death and excessive cost, and seems to not be improving. It is not acceptable. We need to change it.

Friday, May 4, 2018

Health status in the United States and State Health Performance: The Commonwealth Fund report and potential solutions

The Commonwealth Fund has recently issued its 2018 Scorecard on State Health System Performance. This scorecard has data for each state (+ DC, so 51 spots), measuring performance against a variety of metrics evaluating access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities. Because the Scorecard has been issued 2013, Commonwealth can compare the current year’s rankings and performance to previous ones, seeing how states get better (or worse) on these individual measures as well as on overall performance.  

There is not much change. The Top 5 in performance remain Hawaii, Massachusetts, Minnesota, Vermont, and Utah, in the same order as last year. The Bottom 5 (47-51) are Arkansas, Florida, Louisiana, Oklahoma, and Mississippi, and are close to the same, the only change being Florida dropping 5 spots to join the group and displacing West Virginia, now at 46. Hawaii at the top and Mississippi at the bottom are not only unchanged, but remain far ahead or behind of their nearest competitor. The top regions are still the Northeast and Upper Midwest, with the West dragged up by Hawaii and Utah but otherwise an average to low average group.

Commonwealth also ranks the states on degree of improvement of their scores in each of 43 different indicators. More indicators improved than went down, which in itself is a good thing, but there are a lot of caveats. For one thing, it doesn’t measure amount of improvement, or how much less a state might have improved compared to others. For example, Oklahoma joins the list of the top 5 states with improvement on the most indicators (17, to rank it #4), and yet dropped two places in the overall ranking, from a dismal 48 to 50th! This is not good. More important, however, were the areas in which indicators fell for many states and for the nation as a whole. This include rising death rates (a really big one!), including a 50% increase in deaths from suicide, alcohol, and drug use since 2005, rising obesity, and gaps in care with a rising disparity between and within states.

Many of the improvements are in areas that have been focal points of public health policy, like decreasing smoking. This is good, but this long-time-coming advance over the tobacco industry’s heavily funded effort to get people to continue to smoke, and young people to take it up, has still not been entirely won. More important, the lessons from the anti-tobacco campaign have not yet transferred to the other well-funded high-profit threats to health, notably sugar and guns, as well as alcohol and pharmaceuticals. Unfortunately, each of these struggles seems to need to rise up almost as if the others hadn’t been joined; activists can and do learn from the previous ones, but so do industries that manufacture unhealthful commodities. These industries replicate the strategies that tobacco used to delay change for so long. The main one, of course, is the liberal application of money to politicians. The same lobbyists who worked for tobacco work for sugar, and guns, and alcohol; the color of their money is still green, and politicians still enjoy receiving it.

While it is true that many politicians from both major parties have been recipients of such largesse, the retreat from reality-based policy that is the hallmark of both the Trump administration and the Republican Party in Congress has major impact on the causes of illness and will continue to do so into the future. One good example of the latter is the aggressive retreat from environmental regulation, personified by EPA administrator Scott Pruitt, rolling back auto-pollution emissions standards (a decision currently being challenged by a coalition of states led by California). Another is the firm resistance to common-sense regulation of guns, which result in over 30,000 US deaths a year, a tiny fraction of which are from foreign terrorists. Limitations on semi-automatic weapons and high-capacity magazines, waiting periods and background checks, absolutely would decrease the number of these deaths (the majority, by the way, are suicides), but are blocked by legislators feeding from the gun-industry funded NRA trough.

Not only politicians are recipients of graft; a recent New York Times exposé provides evidence of pharmaceutical companies using ostensible “speaker’s fees” to actual provide kickback payments to physicians who are big prescribers of their drugs. The article emphasizes payments to doctors who practice pain medicine and are in a position to prescribe large amounts of the opioids manufactured by these companies. Sadly, this is almost as unsurprising as the graft going to politicians to compromise our health. What we should be is outraged about it, and working to combat it. Certainly the politicians do not seem to be. In the conclusion to her “controversial” speech at the White House Correspondents’ Dinner Michelle Wolf noted that: “Flint still doesn’t have clean drinking water.” It is harsh, it is true, and it is almost as bad as the news that the government of Michigan will no longer be providing free bottled water, even though the tap water is still unsafe.

Flint, of course, is a majority minority and overwhelmingly poor city. It has long been clear that its struggles with lead-poisoned water is not coincidental with the makeup of its population, and it not a coincidence that it is in Michigan. The Commonwealth Report illustrates a wide divide between those states that have better and those that have worse health status. Largely, the map is geographic with northern states better and southern states worse, but there is a tongue of northern states in the worse group, heading up from Kentucky and West Virginia into Indiana, Ohio, and on up to Michigan. What these states have in common with most of those in the south is control by Republicans who in most cases have not, in most cases, expanded Medicaid for their citizens. Expansion of Medicaid was a central part of the Affordable Care Act, but a Supreme Court left the decision on whether to do so optional for the states; those that have not done so have worse population health status. This is exacerbated by changes in federal policy that have increasingly made access to health care worse and more expensive in most states, with the impact felt most in states that have elected Republican government and that voted for President Trump.

In another blog post, First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse, the Commonwealth Fund notes that*:
·        About 4 million working-age people have lost insurance coverage since 2016
·        The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018
·        The uninsured rate among working-age adults increased to 15.5 percent
·        The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent
·        The uninsured rate increased among adults age 35 and older
·        The uninsured rate among adults who identify as Republicans is higher compared to 2016
·        The uninsured rate remains highest in southern states
·        Five percent of insured adults plan to drop insurance because of the individual mandate repeal

This is also not good news. Much of the problem is because employer health insurance costs (much of it passed on to workers) have been rising as Medicare and Medicaid control costs. A Washington Monthly article (excerpted by the great Don McCanne in his Quote of the Day) calls for price controls, noting that much of the cost (in lower wages) that workers bear for higher health insurance is not obvious to them, and they would thus have sticker shock from a Medicare for All program. Dr. McCanne notes that a current California bill, AB 3087, calls for price controls, and is supported by unions but opposed by industry and the California Medical Association so it has little chance of passage, suggesting that this solution is not more palatable to the powerful. He calls for well-thought out Medicare for All program, saying:
Now would it be that difficult to let people know about the hidden costs of health care that they are already paying? Do people really prefer being kept in the dark by an opaque financing system rather than being enlightened by the transparency of financing through an equitable tax system, especially if the amount being spent is somewhat less for all but the wealthiest of us?

I do not think so. It is time to do something to change a status quo that is unacceptable for the health of so many as well as unaffordable. It is time to do the right thing.

*Also summarized by Dr. McCanne

Sunday, April 22, 2018

The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 2

This talk was presented at the 29th Conference on Primary Care Access, Monterey, CA April 16, 2018

Many officials and policymakers pay lip service to the importance of health, but most of the actual support (spelled M-O-N-E-Y) is for treatments for individuals, often with uncommon diseases. Being on the “frontiers of knowledge” is much sexier than rather than the old, pedestrian “taking care of people”. And such policies ensure enormous profit for drug manufacturers, who, like military contractors, are guaranteed huge returns while most Americans are not even guaranteed subsistence.

We abhor the individual excesses of Martin Shkreli and Turing jacking up the price of pyrimethamine (Daraprim ®) from $13.50 to $750 a pill (he has been sent to prison but not for this action against the health of the people; rather he committed the much worse sin of defrauding investors), or Heather Bresch and Mylan raising the price of Epi-Pen ® from $100 to $600, or the manufacturers of colchicine (URL Pharma), with the complicity of the FDA, being allowed to patent a drug that was identified as effective for gout in Egyptian papyri in 1500 BC and raise the price from a few cents to $5 a pill. And what is there to say about the scammer Elizabeth Holmes and Theranos and its A-List Board of Directors?

The Atlantic recently told us the history of the creation and marketing of Oxy-Contin ® by the Sackler brothers. When they bought Purdue, they inherited an expiring patent for extended-release morphine. So they not only developed extended-release oxycodone and marketed it, taking advantage of the public (and physicians’) caution about morphine, they greatly broadened the indications for this drug, which is just as addictive, from cancer and sickle-cell and the like to any chronic pain, especially back pain. Thus, we almost all are eligible users, and we see the results with our nation’s opioid crisis.

If we are still practicing, we see the results of the “breakthroughs” in recombinant DNA “-ab” drugs (actually, anyone who watches TV will see the ads for them), promising (occasionally with some validity) new hope for sufferers from cancer, auto-immune disease, and a variety of neurologic conditions. The TV ads do not contain, and I hope that we as physicians are aware of, the prices, often $30,000 to $100,000 a year or more, far more than the average family income in the US. The frequency of serious side effects, including death, from these drugs is very real – many are immune system stimulants that frequently, not rarely, cause autoimmune hepatitis, pancreatitis and the like – and these are not clearly portrayed on TV, or in marketing to physicians.

Even when the individual is partially shielded from the cost by insurance, the out-of-pocket costs to patients can still be enormous. In any case, no matter who is paying, the pharmaceutical companies are making out like the bandits they are, and less and less money within the whole system is actually available for population health, for prevention, for public health, for treatment of common diseases like hypertension and diabetes. And even for those conditions, we keep seeing newer – and always more expensive – drugs. While all the new diabetes drugs have some use for some individuals, many people with diabetes are still getting inadequate basic treatment with metformin, insulin, and good counseling and support for diet and exercise.

And what can be said about “precision medicine” (sometimes called “personalized medicine”)? Tens, or hundreds, of millions of dollars spent or promised by the federal government, promoted by former President Obama as part of the “moonshot on cancer”, the idea that every individual will have a relatively unique treatment based upon learning and understanding her genetic makeup. The promise is that we will be able to prescribe treatments for cancer and other horrible diseases as precisely as we target antibiotics to the culture results (and, I imagine, overprescribe them as we do with antibiotics). Pursuit of the money being allocated for these “cures”, as well as the cachet of being “scientific industry leaders”, has become a major motivator of medical school deans and chancellors, with every academic medical center developing Institutes for precision or personalized medicine.

What, by the way, has been the outcome? Not much, so far. Two genes have been shown to, themselves alone, cause cancers, and they have been well-known for a long time, BRCA-1 and BRCA-2. And the amazing precision/personalized medicine treatments? Well, get mammography earlier and more often and maybe consider prophylactic bilateral mastectomy. Where are the precision cocktails that cure each person? Do not fret; billions more will be spent on looking for them for years to come.

Is there a problem with this? Taken in isolation, pursuing effective treatments for terrible diseases that affect a significant (if relatively small) proportion of our population is not intrinsically a bad thing. But nothing is done in isolation. Those dollars that NIH spends on looking for these treatments, those insurance company dollars spent paying for outrageously overpriced drugs, the infrastructure development in our academic medical center that continues to support high-tech, high-specialization research and care, are dollars not being used for population health, public health, prevention and primary care, not being used to actually, effectively and broadly implement the treatment strategies that we know work so that they are not only available to but used for the benefit of everyone.

This is what we, as family doctors and primary care providers, and public health workers, can do. It is important, cost effective, and will make a real difference in the health of the population. But because it is cost-effective, it is not profitable for those corporations that have great influence in public policy, and so it continues to be recognized mostly with words and not resources.

Some years ago the VCU Center for Human Needs developed the County Health Calculator. You can click on any state, or any county, and find out the number of deaths per year, number of people with diabetes, cost of diabetes, percent of people with greater than a high school education, and percent of people with an income of at least twice the poverty level. You can compare to the best and worst county or state, and a neat slider lets you see how many lives and dollars would be saved if you had higher or lower percents. Here is Monterey County, CA, where we are. Despite the impression that might be generated by Reese Witherspoon’s HBO show “Big Little Lies”, it is not the richest or best-educated county in the state, but closer to the middle.  Allocating more of our money to addressing core societal functions, like education and poverty, will make a big difference in health, much more than any individually-directed medical care.

It should be obvious that the emphasis in medicine and health care to focus on individual treatments, despite (and maybe because of) huge costs (and remember, costs are someone’s profits!), rather than on interventions to improve the health of our overall population, is totally related to the political and social conditions and circumstances I spoke about at the beginning. We not only feel we are alone, we are actively being encouraged and directed to feel alone, and that we just need to look out for ourselves, and the treatments for our diseases, and our housing and food and children’s education and tax burden, and not for anyone else.

This serves the dual purpose of 1) pursuing, as I hope I have demonstrated for medical care (and others have also demonstrated for military contracting and other areas), strategies that maximize corporate profits, as well as 2) limiting the probability that people will organize together to attack the core structure of cynicism, exploitation, and greed that has become so ubiquitous that we can often not imagine any other way of society being organized.

I have talked about a number of issues, which I think are all related to our health, as individuals and as a nation. I have talked about social isolation, consumerism, a health system that is organized mainly for profit, the excesses of pharmaceutical manufacturers, “precision” or “personalized” medicine, and community health. Changing all of this is about changing society, but I think we, as health professionals, definitely have something to contribute. Whenever we think about these issues, whenever we are confronted by the false idea that we are each alone, that we cannot band together, that we should not care for the others in our society, that there is not value in social cohesion, we need to resist it and increase our efforts to work with others. As physicians and health workers, especially in public health and primary care, we need to continue to demand that most health dollars are spent on the strategies that benefit the health of most of the people.

       While policymakers and subspecialists and deans talk about “personalized medicine”, we as family doctors and other primary care providers, talk about personal medicine.  We are talking about the interactions between people – the medical term for whom is “patients” -- who need to be heard, and validated, and supported, with doctors and other providers who have enough time to do so. This is where the magic of personal medicine happens, not mainly in the provision of ever-more-expensive dangerous drugs and procedures. It is what we know how to do, and need to continue to teach others to do, and it is where we need to direct our efforts. It will not be easy, given the poor pay and resultant shortages of primary care doctors, and the mega-mergers that employ strategies such as retail clinics, currently being adopted. These strategies combine two major themes I have mentioned –  it is “corporate profit meets social isolation and instant gratification”, where people are encouraged to no longer value the relationships that come from continuity and community-based practices. 

We may well be on the road to 1984, even though it’s 34 years late. But I think we can still band together and resist going all the way there.

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