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.

Monday, April 16, 2018

The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 1

This talk was delivered on April 16, 2018, at the 29th Conference on Primary Care Access, Monterey California.

Our society has increasingly become about isolating people and making them feel alone, thus decreasing, and sometimes almost eliminating both social cohesion and any sense of social solidarity. This may seem most obvious when people – not just young people – don’t hear us because they have earbuds in, or walk into us on the street because they are staring at their phones, or worse yet, are looking at their phones while driving – but it is much more serious and profound. In his seminal 2000 book, “Bowling Alone”, Robert D. Putnam re-introduced the term “social capital” (previously used by Alexis deToqueville, John Dewey, Jane Jacobs, and others), to describe a sense of social solidarity and support, the absence of which erodes civil society and decreases political participation. Ways that it is manifested include fewer extended families living with or near each other, greater geographic mobility, and more emphasis by people on their individual, rather than community or even family, lives and achievements. More and more studies point to “loneliness” as a key variable in our health. Evidence has also linked this increased separation to worse health status.

Importantly, this isolation is not simply an organic development in our society. It is also a core manifestation of very late stage monopoly capitalism. What we have today: monopoly (or at least oligopoly) corporations stifling competition, more and more mergers and takeovers with concomitant rises in prices, and stagnant or decreasing standards of living even for most of those living in the richest country on the globe. The stock market may go up, but most people’s lives are not getting better.

Socially, this has resulted in us feeling alone, separated from others and often feeling as if we are nothing but the targets of marketing campaigns that urge us to buy-buy-buy and trade in what we have on something newer – and better! Nothing is exempt, every protest or revolutionary idea is commoditized, from Che Guevara posters to the feminist movement to protest music to environmental concern – all becomes grist for the profit mill. The only challenge for the corporations is how to get us to spend more while paying us less.

More than Adam Smith, or David Ricardo, or Milton Friedman, or any other political philosopher or economist, the world we are living in and moving towards was predicted by George Orwell. 1984 describes massive superpowers in a continual war that provides the justification for suppression of dissent domestically, and the overall thought-control of the state. Does it sound at all familiar? We see some examples of this in the CDC being told it cannot use certain terms, in restrictions on journalists’ reporting, and the refrain of “fake news” every time those in control do not like what the “true news” is.

The only real threat to this status quo would be if people got together and organized, whether against war and nuclear weapons, climate change, the obscene increase in wealth inequality, racism, or health and access to health care. Therefore every effort to do so, from “Occupy” to #Black Lives Matter to the Standing Rock opposition to the Dakota Access Pipeline, to the struggle for universal health care, to, most recently, the struggle to get control of guns and stop or decrease killings both in schools and in the community (#enoughisenough) is challenged and demeaned, and efforts are made to break them up. We are repeatedly told that we are not our brothers’ keepers, that we should not be paying “more taxes” to ensure that our fellow Americans (not to mention people in the rest of the world) are fed, housed, clothed, warm, and educated. Indeed, sometimes even kept alive – see the rising mortality of white Americans (Case and Deaton). White Americans, specifically low-income white Americans, are the only group for which mortality is rising, although it is critical to note that the absolute mortality rate of minorities, especially African-Americans, remains much higher. Even when the things that we feel are in fact shared by many or most others, this is kept secret by the pro-corporate media. When a NY Times poll on taxes shows that most people feel that they pay too much in tax, and that the wealthiest pay too little and should pay more, only the first is reported. So each of us who feels that way thinks we are alone. It prevents us getting together.
How does this manifest in health? I have already mentioned rising mortality. While much of this has been tied to the “opioid epidemic”, it goes deeper; opioids, and other substances, including alcohol, tobacco and other drugs, may be the mechanism of death, but the root causes are social. As a society, for many of us, we have lost our jobs, we have lost our sense that our children’s lives can be better, and too often we have lost hope. Our social structures have not just withered, they are actively being destroyed.

The dominant narrative changes to meet these structural needs, and almost always plays on the racism upon which this country was founded. For example, during the “War on Drugs”, the assumption was that users were mostly minority and were called “addicts” and were at fault and were to be punished; now that users are more and more white and have had their drugs prescribed by physicians, they are “victims”. When a white man commits mass murders by gun or bomb (as recently in Austin, Las Vegas), he is the problem – troubled, mentally ill. When a minority or Muslim person does, it is a reflection on their race or religion.
In fact, they are all victims, and we are all perpetrators..

The ACA helped many people gain financial access to medical care, but even if it is not completely dismantled, that care is becoming less accessible, and costs are going up for many patients. Medicaid, and even Medicare, are in the sights of those who are seeking ways to fund the enormous tax cuts that they passed for the wealthiest individuals and corporations. People continue to go without health care, especially without prevention and early diagnosis and treatment, the kind of care that family physicians, provide. The US remains the only industrialized country without a national health system, insurance, or service, and our thought leaders continue to insist that such a program is inaccessible.

In a recent JAMA article, Papinicolas, Woskie, and Jha compared the costs of care in the US to ten other wealthy countries. They observed that the US has “administrative costs” (including profits) almost 3 times that of other countries, that we pay more for procedures and for drugs, and that a big part of the problem is that we have a higher percentage of poor people. Shockingly, the coverage in the NY Times, especially by the headline writer was, in the online edition “Why Is U.S. Health Care So Expensive? Some of the Reasons You’ve Heard Turn Out to Be Myths”, and perhaps even more inaccurately in the print edition, “United States healthcare resembles rest of world”.

What? Anyone who has been to this conference before, anyone who is awake, in fact, knows this is not the case. To extract these headlines requires both careful cherry-picking of the data, as well as including such falsehoods as “40% of US physicians are in primary care”. That would be news to all of us in primary care; it is, in fact, also known as the “Dean’s Lie”, maintaining that everyone entering Internal Medicine is in primary care, when 80+% become subspecialists and more than half the remainder hospitalists.

And what about the fact that we have so many people in poverty? Does this somehow excuse our high cost – and frequent inaccessibility – of care? Or should it, rather, be a wakeup call, an assertion that things are NOT OK, that we need less inequality and, like the other countries studied, a better safety net to ensure that not only medical care but the major social determinants of health – housing, food, warmth, education, safety – are in place for all Americans. Pundits persist in their “unaffordable” argument although it strains credulity in the time of trillion dollar tax cuts, and continue to use un-Americanism as a justification for avoiding “socialized medicine”. Apparently, to them, Americanism includes the right to do without health care, be sicker, and die younger.

To be continued...

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