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”,
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.
No comments:
Post a Comment