Other countries invest in the public's health and welfare. We invest in creating billionaires. ???

It’s not just Donald Trump. It would be nice to think it was, and that, if it was far from perfect, everything was much better in the US before him. Maybe it was; certainly many of the horrible things that he and his administration have done were not done by previous administrations, of either party. These include total denial of climate science (or any science), overt (not subtle) racist appeals, gutting most of the federal agencies responsible for the quality of our life (not to mention survival of our planet) in areas such as health, environmental air and water quality, education The administration has replaced of most of the protections we have had with the most rapacious policies we have seen. Oh, yes, and destruction of our relationships with our allies, and moving ever closer to war with – almost anyone, although his friendship and authoritarian bromances with many of the world’s most autocratic leaders might limit that.

And it’s not just his supporters, as nice as it would be to think that they are just stupid (as long as they do not remain the majority, or the effective majority given the intrinsic inequities of the Electoral College). While the most of them may be stupid and have no understanding of where their own self-interest lies, or are at least more committed to racism than their self-interest, there are a minority of them who are smart (if not wise) and very rich people who have been quite pleased with the direction of (most) of the administration’s policies. That is why they fund it.

And it is not even the Republican Party, as much as that party has, at least for 4 decades, been the party of giveaways to the richest, destruction of the environment, bellicosity which has led to several horrible and pointless wars, appointment of right-wing Supreme Court and lower court justices who manage to convince themselves that they know what the “founders” would have thought 250 years later about issues that they could not imagine, and of course racist approaches to almost everything.

But the most important general trend in the United States over the last 40 years, while it has sometimes been accelerated by Republican administrations, has continued under the Democratic administrations of Carter, Clinton, and Obama. It is the increasing, ever increasing – and incredible, at this juncture -- concentration of wealth in the hands of a few, to a degree that has not existed since the days of the “robber barons” of the late 19^th century. A recent article in the Guardian, ‘The US has the most billionaires in the world – but here's what it doesn't have’ documents what citizens of other industrialized have that we don’t: low-cost, or even free, college education, universal health coverage, guaranteed paid vacation and paid parental leave. And more. And, of course, we also do not have what the article refers to as an “inhospitable climate for billionaires, one in which they actually have to pay taxes commensurate with their income and wealth. Our climate is definitely hospitable for them. And, thus, if you are both a billionaire and a completely selfish immoral person, you should be happy with US policies. If you are neither, or only one, you should not be.

There is obviously no disconnect in between these two things, the hospitable climate for billionaires and the limited programs that benefit our people. In the 1950s, as our economy and that of the rest of the world, rebuilt from World War II (ours rebuilt faster because, after the bombing of Pearl Harbor, there was not actual war fought on our territory), under the Eisenhower administration, employment, wages, and unionization increased. The wealthy were wealthy, but regular people, workers, found unprecedented economic success, buying houses, cars, and sending their children to college. CEOs made about 30 times what the average line worker made – a lot more. Of course, the growth was not equitable; minorities and particularly African-Americans were still marginalized, but even many of them got decent jobs.

 In the 1960s, mainly under the Johnson administration, the federal government developed programs to help Americans at a level not seen since the New Deal of the 1930s. In addition to passing laws like the Civil Rights Act and the Voting Rights Act, it developed programs to aid the neediest in our country, both Medicare and Medicaid, and the “War on Poverty”. That “war’s” programs are often derided, by the right, as a failure, demonstrating the fatuity of “throwing money at problems”, but in fact this narrative is incorrect. While the US did not “end” poverty, it decreased poverty a whole heck of a lot. Expansion of programs such as Aid to Families with Dependent Children (AFDC) and food stamps and the Fair Housing Act kept millions of children in homes, with food. The development of HeadStart made a real difference in early childhood education. As with most social service programs, the failings were almost entirely the result of not doing enough, not spending enough, and not a result of doing and spending too much.

But the money the government was spending needed to come from somewhere. And relatively more equitable taxes was more than the wealthiest wanted to pay. Of course, most people didn’t and don’t want to pay taxes, but the billionaires had a lot more clout to get what they wanted. So they got tax breaks for themselves and their corporations, and huge expenditures for “defense” (the US spends more than the next 10 countries together), really just another way this country subsidizes its corporations, and this became the order of the next four decades. Beyond not taxing the wealthiest, the US has subsidized them.  This is well-described by Paul Krugman in his recent piece “Why Do the Rich Have So Much Power?” (7/1/2020). Every penny spent on helping the neediest, or kept by the average American, is another penny not in the pocket of billionaires who are apparently possessed by the desire to have endlessly more despite the fact that they will not be able, in their lifetimes and those of their descendants, to buy enough mansions, private islands, planes, and yachts to spend it all.

Then comes a major crisis, like the COVID-19 pandemic. It hits everywhere in the world. Not equally, of course, the poor and the old and minority communities and the disenfranchised are hit the hardest. But a great deal of the first wave was in developed countries. Some were hit particularly hard, like Italy and Spain, and then France and Germany. Some responded aggressively and limited the damage, like the Scandinavian countries (except Sweden). But the US has responded abysmally poorly, with the most infections in the world – 25% of all COVID-19 cases in a nation with 4% of the world’s population. And tens of millions of unemployed people. And hungry people. And, increasingly, homeless people. Because we have not only, over the decades, purposely decimated our public health infrastructure, we have purposely inadequate social infrastructure of any type. While, in this pandemic, the people of other developed countries get cash bailouts, and expansion of the social support systems that we never had, the US expanded (for a little while, we don’t want to go too far!) unemployment insurance and gave folks one-time $1200 checks. Thus the NY Times can report that “Europeans get paychecks. Americans scrounge for food” (7/3/2020). And, thus, as reported by Robin Wright in the New Yorker “To the World, We’re Now America the Racist and Pitiful”. They used to envy us; now they pity us.

Some years back, I was amazed to hear the chair of one of the highest-income departments say they couldn’t afford nurses, and could only have medical assistants in their clinic. Since my department was one of the lowest income, and we did have nurses, I initially didn’t understand. But then it came to me.  Our group hired the nurses and medical assistants we needed to run a quality practice, and paid what was left to our physicians. Their department paid their doctors (i.e, themselves) what they thought they deserved, and then looked to see what might be left to pay staff. A different approach. There are a couple of ways, generally speaking, a society can  allocate resources: one is to spend what is necessary to meet the needs of the people, with the remainder going to profit, or savings, or (if this is the goal) to enhance the wealth of the rich. The other is, well, the opposite – give the rich what they want and see what is left over.

In ancient Egypt, we are told, Joseph advised the Pharaoh to stash away reserves of food when times were good in case they were needed in the future. As the 7 years of plenty wore on, there were certainly those who must have said “Enough!” But then came the 7 years of scarcity, and the Egyptians were glad that they had saved. We haven’t, on purpose, because our purpose has been to make the richest richer and preparing for real problems that might befall the rest of us was not really high on the agenda.

We have not been meeting the basic needs of our people in the best of times. Poverty and racism are key social determinants of health, and for too many of us, our pre-existing health was marginal. We do not have affordable, universal health care. And we have cut resources for public health planning and preparing for a crisis, such as that we face today. For most Americans, that is a double hit, and for the poorest and worst off, it is unconscionable. This needs to change, and it needs to start immediately. Equitable taxation, meeting the needs of our people, and planning and preparation for the future.

Or, I guess, we can just keep funneling money to the billionaires.

Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters

The election of Donald Trump as President continues to be extensively analyzed. It demonstrates major divisions among our populace. One of those that has been discussed a lot is that the “white working class” that voted for him by a 2:1 margin will suffer a lot from the policies likely to be implemented by his administration. Not more, and probably less, than minority people, but a lot.

Healthcare and health insurance is one of those areas, as discussed by me in several recent posts and by Paul Krugman in the New York Times, December 2, 2016, “Seduced and betrayed by Donald Trump”. He notes that anger about their health care coverage, and in particular the dramatic increases in premiums under the ACA exchanges, drove many people to choose Mr. Trump’s promise to replace it with “something terrific”. Of course, he never specified what that would be, for the same reason that the Republicans in Congress have never been specific, which is that any replacement plan that does not move “left” toward a more universal coverage plan such as the single-payer advocated by Senator Bernie Sanders (and me) will be much worse for most people, including most Trump voters, who will either lose or have to pay a lot more (if they can!) for their health insurance coverage. Repealing Obamacare means that many of the 13 million newly insured (a majority white, for the record) who received insurance under the exchange will not get rate cuts, but rather they will get no coverage. Certainly not those who need the insurance most, because they have pre-existing conditions that insurance companies were mandated by ACA to cover. As Krugman puts it, “we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.” This is made clear in the Times article on December 3, 2016 “GOP plans immediate repeal of health law, then a delay” by Robert Pear, Jennifer Steinhauer and Thomas Kaplan. The reason is because the only plan they have will yank health insurance coverage for so many people, and despite their vociferous opposition and multiple votes to repeal ACA, they do not want to do that, at least right away.

The best evidence for their long term plan to, basically, remove health insurance coverage from many Americans including their base of support is the appointment of Rep. Tom Price (R, GA) as HHS Secretary. Mr. Price has been a leader of the Tea Party movement and a major Congressional figure calling for the repeal of Obamacare. His solution is not completely fleshed out, but does include eliminating guaranteed issue, community rating, and federal support for the exchanges. He is a fan of vouchers, an idea advocated for decades by conservative think tanks, and which, I guarantee (and this is far more of a certainty than Mr. Trump’s promises), can NEVER work, especially over the long term. Vouchers will never cover the cost of a decent insurance policy; people with health problems will naturally be the first to seek coverage, and faced by the adverse selection insurers will raise the premiums, co-pays, and deductibles for them. If there are problems with this under Obamacare, vouchers will make those look pale by comparison. And by getting out of the running-the-infrastructure business, the government will ensure that it never gets better.

Price, a wealthy orthopedist from suburban Atlanta, does not really care. He represents rich doctors who want to be able to charge whatever they want to be able to charge, and care only for the people who have insurance good enough to pay it. Sorry, Trump voters with not much money, chronic disease, and difficulty paying even ACA premiums, that isn’t you. And when you get to an age that you can get Medicare, finally having federally-supported coverage, Mr. Price has another answer for you – privatize Medicare! Make it subject to the same market forces that have made health care and health insurance so unaffordable and unavailable to younger folks affect the elderly too! The ACA has modified the egregiously negative impact of private sector health insurance for the under-65 group; the crumbum Price wants to both reverse that benefit and extend the damage to seniors too.

When Lyndon Johnson signed the Medicare law at the Truman Library in 1965, presenting Harry and Bess Truman with cards #1 and #2, he quoted the former President from nearly 20 years earlier: "Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection." LBJ then added that “There are more than 18 million Americans [in 1965; way more now] over the age of 65. Most of them have low incomes. Most of them are threatened by illness and medical expenses that they cannot afford. And through this new law, Mr. President [referring to Mr. Truman], every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”

This is what Tom Price and his colleagues want to reverse. The AMA, with its shameful history of actually having blocked Truman’s health plan, and unsuccessful opposition to Medicare, is endorsing him. The Association of American Medical Colleges (AAMC) is endorsing him as well. The American Academy of Family Physicians (AAFP) more tepidly expresses optimism. Presumably these are political decisions, to maintain access. After all, in the ongoing battles between insurers and providers (patients are rarely a real player), at least he is a provider. But many others, including Physicians for a National Health Program (PNHP) and Common Dreams, as well as the medical students of Future Docs, have appropriately condemned Price and these organizations endorsing him.

Mr. Price will be joined by Seema Verma, who will head the Center for Medicare and Medicaid Services (CMS). Verma helped Mike Pence design the Indiana version of Medicaid expansion. On the plus side, that state did expand Medicaid, helping people more than those states that did not. On the minus side, the requirement that everyone covered has to pay meant at least 1/3 of those who would have been eligible did not sign up. I guess she is the moderate!

Mr. Trump’s cabinet picks are, so far, a panoply of people who are either right-wing ideologues who wish to destroy everything that has been done to help the American people at least back to the Great Society and maybe to the New Deal, or are billionaires who speak for the corporate financial ruling class that he attacked so effectively during his campaign, or both. An example of the latter is anti-public education billionaire Betsy DeVos to head the Department of Education. Myron Ebell, a noted climate-change denier, will head EPA. Steven Mnuchin, a leading Goldman Sachs banker, will be Treasury Secretary. Senator Jeff Sessions (R, AL), denied a judgeship because of his racist beliefs and practices will be Attorney General. Trump's nominee for Commerce Secretary, Wilbur Ross, according to Money, alone has 10 times the net worth of the entire cabinet of President George W. Bush. Talk about foxes guarding the henhouse! Compared to these folks, naming El Chapo to head the DEA, as suggested in a New Yorker satire by Andy Borowitz, would be a moderate pick.

The future of not only public health, but also your individual private health, now and when you get to retirement age, is in great jeopardy. But, then, so is everything else that helps people. Not to mention the earth, since global warming is likely to accelerate during a Trump administration. There is an endless string of battles before us.

And we must join every one.

ACA: Where are we? And where should we go?

I am finished writing the book, as yet untitled, that I have been working on during my sabbatical, which accounts for the sparse number of blog posts. This is not to say that the book is anywhere near ready to be published; I am sure it will need more revisions.

However, it does mean that I am likely to be posting to the blog more frequently, as I find things that inspire me to write.

Thanks for your patience!
Josh

The Affordable Care Act (ACA) has been law since 2010, and was supposed to have been fully implemented this year in 2014, although as is clear many of its provisions have not yet been. The most important has been the failure of about half our states to implement the expansion of Medicaid, which was the mechanism through which the law intended to cover all those poor (incomes under 133% of the federal poverty level) who are currently ineligible for Medicaid (most of those now receiving it are poor children and their mothers, although the majority of dollars are spent on nursing home care). This is legal as a result of the Supreme Court decision that was important because it made the rest of the law legal; this is, I think, of faint solace to those poor people who live in my state of Kansas and the others who have failed to expand Medicaid despite the fact that the federal government would have paid 100% of the cost for 4 years, then 90%.

The newest court actions that affect ACA are two Court of Appeals decisions which say, basically, opposite things about the subsidies that support the premiums of people making above 133% of poverty but less than allows them to pay the full amount.[1] One court decided that people living in states that ran their own exchanges were eligible for the subsidies, but that those who were in federally-administered exchanges were not. The other appeals court decided that both were. Of course, those states that have federally-administered exchanges are those with governors and legislatures who oppose ACA completely; they include all those who did not expand Medicaid plus many more (about 36 altogether). This suggests some political agenda; the interpretation of Congressional intent rather than parsing the words, has historically been the basis for such court decisions. It also will mean that the cases will go to the Supreme Court, sometimes known as SCOTUS, but now appropriately called COCUHL (Court of Citizens United and Hobby Lobby), where it will be amazing if a conscious, careful, legal approach supersedes politics. The decision to basically gut the Hobby Lobby decisions one remaining protection only a day after it was announced bodes ill. The Republicans in Congress have decided to sue President Obama for not implementing portions of the ACA, which, as Timothy Egan of the NY Times points out, “…they have tried to repeal more than 50 times.”[2]

What has the Republicans so flustered that they have taken to self-contradictory actions is, in fact, the success of the ACA at achieving many of its goals. These are summarized in another NY Times op-ed, by Paul Krugman, titled “Obamacare fails to fail”.[3] There has been a huge surge in enrollment, and while indeed some people are paying more (largely healthy young people who are low risk for high-cost illness, thus previously had lower premiums), most people (including 74% of Republicans) are happy with their current premiums. In addition to the early wins (preventing insurance companies from not covering those with pre-existing conditions, allowing young people to stay on their parents’ insurance until they are 26), we now add over 6 million people who are newly covered, and can access health care. Despite decisions such as Hobby Lobby, most women will now get contraceptive coverage without a copayment. It is a good thing. This is why opponents (mainly ideological) are trying any trick that they can to limit its effectiveness, including the two biggest addressed above—not expanding Medicare and trying to block subsidies for those on the federal exchanges. That is to say, trying to limit health insurance coverage to our less-affluent citizens.

But ACA, even if it came through all the court decisions unscathed, is not a solution. It doesn’t cover those who are not citizens, even though they live here. It is a gift to insurance companies, who still get to charge high rates and make enormous profits, but now have the federal government paying the premiums. Therefore, it will not really save cost. Don’t get me wrong – I am not advocating that we provide less of the health care people need to save money (although I do advocating not providing “health care” that will not help or even harm people just because someone can make money on it). I am saying that the huge profits guaranteed for insurers, and other components of our system who make profit, make it excessively costly. It costs us way more per capita, for poorer health outcomes, than do the healthcare systems of other developed countries. The latest edition of “Mirror, Mirror on the Wall”, published in 2014 by the Commonwealth Fund demonstrates this clearly; in comparing 11 wealthy countries the US ranks #11 overall, and #11 in 3 of the 5 areas examined (Efficiency, Equity), and Healthy Lives), #5 in Quality, and #9 in Access. It achieves this less-than-mediocre performance by spending (2011) $8508 per capita, while the other 10 countries spent from $3182 (New Zealand) to $5669 (Norway).[4]

The problem is not that our system is not working, but that it is. Paul Batalden is famous for saying “every system is perfectly designed to get the results that it gets”, and ours is. The results that we get are relatively poor health outcomes on a population basis, large numbers of people excluded from health care coverage (even after ACA), many people getting unnecessary care because someone can make a profit on it, and the bizarre concept that there are not only people who are preferable to provide care for (because of their wealth or insurance status) but even diseases that it is preferable to provide care for (because the profit margin is better). Our system is not designed for people’s health; it is designed so that some (providers, insurers, drug companies, etc.) can make profit. It gets the results it is designed to get.

But that is unacceptable. We need a health system designed to maximize the health of our people. All our people. And we need it yesterday.

---

[1] Goodnough A, Ruling on Health Care Subsidies Puts Coverage at Risk, NY Times 7/23/14, http://www.nytimes.com/2014/07/24/us/politics/court-ruling-on-health-care-subsidies-risks-loss-of-coverage.html

[2] Egan, T, “Ambulance Chaser in the House”, NY Times, 7/26/14, http://www.nytimes.com/2014/07/26/opinion/timothy-egan-Congresss-Next-Big-Idea-Sue-Obama.html

[3][3] Krugman P, “Obamacare fails to fail”, NY Times, 7/13/14. http://www.nytimes.com/2014/07/14/opinion/paul-krugman-obamacare-fails-to-fail.html

[4] Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2014 Update, The Commonwealth Fund, June 2014. http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

"Call the Midwife": If Britain could afford to create a National Health Service after WWII, we can now!

The main argument against not cutting (not to mention expanding) social services, including health care, for the most needy, is that we “cannot afford it”. This is the argument of the governors and legislatures in states that have refused to expand Medicaid, despite clear and convincing evidence that it will cost states much more to not do so (see Medicaid expansion will leave out many of the poorest: What is wrong with this picture?, May 26, 2013). This is portrayed in a very funny – except it’s really not -- “Daily Show” segment, cited by Dr. Allen Perkins in his blog, “Training Family Doctors”, Medicaid Expansion by the Numbers. Not being able to “afford” it is the mantra not only in the US, but also across Europe as those austerity hawks have been cutting off their people’s noses – and their election chances – in thrall to a false god.

So it was very interesting for me to watch the first episode of the British (BBC One) television series (now in its second season) “Call the Midwife”. Set in a poverty-stricken area of East London in 1957, midwives pedal their bicycles around the crowds of people and rubble that still covers the streets more than a decade after the end of World War II to attend to

pregnant women in their homes, delivering prenatal care and babies and even caring for the babies afterward. It is a not a beautiful scenario; the young midwife, Jenny Lee (based on the real life midwife Jennifer Worth, whose memoirs form the basis for the series and who died in 2011) has never seen such poverty, such crowding, such filth, so many children. It is the height of the “baby boom”, attributed initially to returning GIs who had to wait to start their families, but continuing with no end in sight; the women portrayed are having their fourth or fifth baby in their early 20s and many far more. In fact, of course, the end of this “boom” was not the aging out of the reproductive population but the introduction of effective and widely available contraception (especially birth control pills) in the 1960s.

The midwives, all nurses and many Anglican nuns, set up clinics in a gym in the interval between the pensioners’ breakfast and the evening dance classes, as well as attending women at home. They practice an obstetrics that is quaintly anachronistic, both in its tools (the wooden “fetoscope” to amplify the fetus’ heart sounds, and the glass rectal tube), and in practice (shaving the pubic area and administering enemas – “high, hot, and a helluva lot!”) but they provide much safer pregnancies and deliveries than had ever been available to this population in the past. At one point, a woman in her 23^rd (!!) pregnancy (already with 24 children, because of two sets of twins) goes into premature labor and the midwife is there to deliver what seems to be a stillbirth and begin care for the hemorrhaging mother while awaiting the arrival of the “obstetrics flying squad” with its ambulance, obstetrician, and pediatrician to continue to care, including blood transfusion in the home. When, miraculously, the baby comes to life, the mother refuses to send it to the hospital, feeding it milk with a dropper. The senior midwife tells Jenny that “we don’t ever care for these babies anymore; in the old days they died; now they go to the hospital.” When asked what they will do, she tells her they will visit three times a day until the baby is stable, and then at least once a day thereafter. In the home.

It is a dramatic and engaging story, but what fascinates me is that these services were available to these poor women. Home visits for prenatal care and delivery. Visits from nurses three times a day. An obstetrics “flying squad” to come to the homes of women who would otherwise die in childbirth. Where did the money for these services come from? Who paid these midwives, and these flying squad doctors? Well, the National Health Service (NHS). The NHS, established after the war, in 1948, to provide health care to all people in the UK. Not established at a time of prosperity, when we could “afford” it, but right after World War II, with both the nation’s economy and its literal infrastructure in shambles, with the piles of rubble still on the streets of London in 1957, 15 years after the Blitz. The National Health Service was not founded as a gesture of magnanimity from the wealthy, but as but as an explicit and well-thought out policy to provide one of the most basic of needs, health care, to all of the British people even though there was not much money; it was seen as a priority. In the second episode of "Call the Midwife", a woman who has lost 4 babies because of a pelvis contracted from rickets (vitamin D deficiency in childhood) is delivered of a healthy baby by Caesarean section. Rickets itself, the senior midwife says, is a disease of poverty and malnutrition eliminated by the NHS.

From the time I went to college and met upper-middle-class people, through my career as a doctor when I know lots of them, I have heard “horror stories” about the NHS, about the waits for things “we” never have to wait for, like elective surgeries. “My cousin says”, or “the people we had visiting from England told us”. But it was always apparent to me that this was a skewed group; the folks visiting from Britain on holiday were not the poor, were not the Welsh coalminers who had never had health care before. It is hard, I guess, when you have always been at the front of the queue, when the queue has always been so short for you that you didn’t even know there was one, to have to take your place in it; to wait in line with the hoi polloi. But ask those who never had had care, ask the poor, ask the women having babies in the Docklands.

My point here is not to romanticize poverty, or to suggest that things have always been perfect with the British NHS. It is, rather, to say that the provision of basic health care to all people is not and never has been a question of economics, it has always been a question of will. We can afford do it; indeed we cannot afford not to. Not only is it a “good investment”, it is essential humanity. Paul Krugman calls the group of health care expansion opponents “The Spite Club”, (June 7, 2013), arguing convincingly that their opposition is ideological, not fiscal. It is doubly sad to see this ideology acting in Europe, cutting the social safety net that has been in place there for decades.

When you think about what we can “afford” in health care, think about midwives making home visits to premature infants three times a day in the poorest areas of London in 1957. The expansion of Medicaid under the Affordable Care Act (Obamacare) may not be the best vehicle to bring care to the poorest (I still argue for a single-payer, Medicare-for-all, system), but opposing it is not fiscally responsible; it is both fiscally and morally reprehensible.

Improving health in poor countries -- and reducing it in the rich

I have recently published the text of my “Withers Lecture” on Social Justice and Health, given at the University of Texas at Houston. In its May 16, 2012 issue, . JAMA published two important “Viewpoint” articles: “Policy making with equity at its heart”,[1] by Michael Marmot, FRCP, and “Primary Health Care in Low-Income Countries: Building on Recent Achievements”,[2] by Jeffrey Sachs, PhD. It is gratifying that these two major figures are writing about the same issues that I am; after all, I cite Dr. Marmot (Sir Michael) in my talk, both for his seminal work on the impact of social class on health (the “Whitehall studies”) and his more recent work as President of the British Medical Association in taking the lead on involving the medical community in addressing the social determinants of health. Dr. Sachs, of the Earth Institute at Columbia, is one of the most important thinkers and actors in the field of international health.

But, in another sense, I am sobered by this, because it is often true that an outpouring of articles citing the evidence for the importance of social action, whether from leaders such as Drs. Marmot and Sachs in JAMA or by bloggers such as myself, are stimulated by attacks and cut-backs in these areas which have already resulted in pain and suffering. Dr. Sachs’ piece is, in this sense, more positive; he reviews successes that have been achieved in poor countries by the use of primary health care strategies. Much of this success has been in “Group I diseases [which] include communicable, maternal, perinatal, and nutritional diseases”, and which he points out are very susceptible to improvement with quite low levels of investment. The successes he points to include reducing the infant mortality rate in many countries (“In the least developed countries, approximately 112 of every 1000 children die before their fifth birthday, as opposed to 8 per 1000 in the developed countries. With a concerted science-based effort, the under-5 mortality rate of the least developed countries could be reduced to less than 30 per 1000 by 2020. Such low under-5 mortality rates have already been achieved, for example, by the Dominican Republic (28 per 1000), Mexico (17 per 1000), and Thailand (13 per 1000).”) He also addresses the issue of malaria, one of the world’s great killers: “Malaria deaths in Africa have declined an estimated 30% from their peak around 2004 with the partial deployment of this new and evolving system.” His article is positive and optimistic, particularly when examining the relatively low cost of interventions that will have such great impact: “Small investments in improved health of the poor have a remarkable return in reduced morbidity and mortality.”

Whether those small investments will continue to be made, however, is an open question. The flamboyant, aggressive, and unabashed attacks on people demonstrated in many laws passed on both the Federal and state level in the US, and the dramatic cuts in social services that have occurred here and in Europe as a result of “austerity” policies”, challenge our ability to maintain health even in developed countries. This is a focus of Dr. Marmot’s article. In a pointed and engaging opening, he writes “In India, there is a cabinet minister for social justice. Would that it were catching, and spread to all government ministers. What a thought: social justice at the heart of all government policy. It would be a radical change from the current set of arrangements, in which many governments are unashamed apostles of self-interest—of their countries, of their partisan supporters or, indeed, of self-interest as a political creed. Given the link between social and economic policy and the health of populations, all ministers should see themselves as ministers of health.”

What a thought, indeed! Dr. Marmot, like Dr. Sachs, cites a list of health problems that could be largely addressed by social intervention and a concern for equity. Unlike those on Dr. Sachs’ list, however, these are interventions are being curtailed rather than expanded. He cites the report “Closing the Gap in a Generation” from the World Health Organization’s (WHO) Commission on the Social Determinants of Health (CSDH) and emphasizes that “…although traditionally efforts to prevent ill health have focused on causes—such as inadequacies in sanitation, nutrition, and shelter in deprived populations, and on unhealthy environments and behaviors among those not deprived—focus should shift to the causes of the causes.” And the cause of the causes is social and socioeconomic inequity – not inequality, because it does not require that everyone be equal – but inequity, which he defines as “systematic inequalities in health between social groups that are deemed to be avoidable by reasonable means.” He challenges the international focus on solely achieving growth of GDP, which has generated the austerity measures that have already caused so much suffering, and instead suggests considering the “…report of the Commission on the Measurement of Economic Performance and Social Progress (established by the French government and led by Joseph E. Stiglitz, Amartya Sen, and Jean-Paul Fitoussi) that argues for broader measures of social and economic progress than simply GDP.” And, as argued by another Nobel Prize winner, economist Paul Krugman, austerity policies don’t even do much for growing GDP!

So, while progress in health has been made with small investments in developing countries, developed countries are seeing both their health and social structure degraded as “solutions” to a financial crisis brought on by the greed of multi-billionaire bankers and investors. These “solutions” are implemented in a way that ensures that the prosperity of those perpetrators is guaranteed while the price is paid by the middle and lower income groups. These “solutions” have neatly dovetailed with radical right-wing (often incorrectly labeled “conservative”) social agendas. This is true not only of cutbacks in direct support for social programs, but in union rights, and most profoundly in the rights of women to protection from violence, opportunity for education, and control of their reproduction. The systematic and hypocritical character of these attacks in the US is well-documented in a New York Times editorial from May 20, 2012, “The Campaign Against Women”.  

While Sachs may be correct in noting that the in developing countries improvement is low cost, his concern that this is not happening sufficiently “While the developed economies grapple with health systems that cost several thousand dollars per person per year and often spend hundreds of thousands of dollars on a treatment to eke out an additional few months of life,” may also miss the point. In developed countries, we spend on this high-tech, high-profit, low-yield medical interventions but we still do not spend on the social interventions that would truly make a difference in health.

Perhaps progress in the developing world can be a model for the rest of us. 

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[1] Marmot MG, “Policy making with equity at its heart”, JAMA. 2012;307(19):2033-2034. doi:10.1001/jama.2012.3534

[2] Sachs J, “Primary Health Care in Low-Income Countries: Building on Recent Achievements”, JAMA. 2012;307(19):2031-2032. doi:10.1001/jama.2012.4438

Reproductive Rights -- and wrongs

The “debate” on reproductive rights has taken a turn to the far right with recent laws passed in several states that create greater obstacles for women who wish to obtain abortions. Probably the most famous commentary is a series of Doonesbury strips that ran (or didn’t run, or ran on the editorial page, depending upon your hometown paper) from March 12-16. Its focus is the Texas law requiring, among other things, that women have a transvaginal ultrasound examination before obtaining an abortion. It also requires that they receive “counseling” scripted not by their physician but by the state legislature and governor (see the final strip in the series, March 16).

Unquestionably, the “Doonesbury” strips are effective but face an uphill struggle in the effort to counterbalance the extremely well-funded efforts of right wing organizations. Their “think tanks” have been writing bills that are introduced in many states with virtually identical language. For an excellent discussion, see Paul Krugman’s “Lobbyists, Guns, and Money” (itself a parody of the title of a Warren Zevon song), about the American Legislative Exchange Council, ALEC, in the NY Times, March 26, 2012. Kansas, my home state, is in the process of passing a bill that will require doctors to inform women of the increased risk of breast cancer from having an abortion. This might seem reasonable, except that it is simply not true.  How can they get away with this? Well, we can examine the syllogism, which goes something like this: there is a somewhat higher rate of breast cancer in women who have never had a term pregnancy, so if you have an abortion instead of carrying to term you might be in this higher risk group. Of course, this misses a whole lot of bases. Women who have abortions frequently have had previous term pregnancies (which sometimes contributes to why they want the abortion), and or they may have term pregnancies later. Even if they never have a term pregnancy, no one has ever studied whether having a pregnancy at all (even one ending in abortion) puts one in the higher or lower risk group, or in the middle. Most important, for this discussion, most of women who never get pregnant do not get breast cancer, and many (probably most) women who do get breast cancer have had babies. Having a term pregnancy, or multiple pregnancies, is not protective.

Of course, this is not really the issue. The issue is that anti-abortion forces wish to prevent abortions by making it more difficult for women to obtain them. Thus, the veracity of the information that the laws written by ALEC promote is not important to its supporters. There has been some discussion about the fact that these laws that affect women but are written and passed primarily by male lawmakers. The suggestion is that it indicates a profound misogyny. I agree. These guys are often flagrant hypocrites who indulge in sexual (as well, of course, of financial) shenanigans, but feel no compunction about limiting the rights of women. This view is prominent in both the Doonesbury cartoons and in this creative effort by Salt Lake City Dispatch political cartoonist Pat Bagley in which he attaches the “I thee rape” Doonesbury, not run by that paper, to his own critique of this hypocrisy. It is the same misogyny which not only leads to abortion restrictions, but to restrictions on the availability of contraceptives, one of the two things that actually reduces the abortion rate (the other being accurate and widespread sex education, another “no-no” for the right), through insurance plans.  While, of course, ensuring that that these same plans cover Viagra and other drugs that help old guys get erections. It is part of worldview that sees men and women as not only different, but hierarchically related with men firmly in control. Women are subsidiary, not supposed to make noise, do what they are told, and certainly not make any decisions about their own lives, health or reproduction.  

Those who oppose abortion, but also support contraception and sex education, have a coherent position. The imaginary story line is that once a woman is forced to have a baby, she will want to keep it and care for it and be able to do so, or, at least put it up for adoption where someone else will do so. But while sometimes one of these two things happens, it is obviously a fantasy to think that it is the norm. We all hope that all children can be brought up in a loving, supportive, and financially secure family, whether birth family or adoptive, with all options open to them. But this is simply not the case for too many children, and those opposed to abortion are not doing anything to make it more likely by cutting support for health care, childcare, and education. Which is, of course, one reason it is hard to call them pro-life (along with their support for war and capital punishment).

Another part of the Kansas law forbids state employees from doing abortions. This might seem unnecessary, since it is already state law that abortions cannot be performed (with some rigid exceptions to save the life of the mother) at the University of Kansas Hospital, the only state owned facility. It also might not prevent medical school faculty from doing abortions at other facilities for which they are paid with funds that come from the physician practice plan rather than the state. It does, however, directly affect residents, physicians in training, especially in obstetrics and gynecology (OBGYN). The accrediting body for OBYN requires that residents receive training in abortion (which they may opt out for religious or moral reasons) and in evacuating the uterus when there are stillbirths (which involves the same procedure), which they may not opt out of. Currently, OBGYN residents at KU who do not opt out of abortion training receive this in an out-of-state program, but if this bill passes intact it would forbid them from doing that, as the residents are state employees. This would put the entire OBGYN training program in jeopardy, and it would likely be placed on probation, potentially closed, a problem noted by even some usually anti-abortion legislators. But to the anti-abortion movement, this is not a problem. They see this collision course as desirable and hope that a series of such state laws would force the OBGYN accrediting body to eliminate this requirement. Then, ultimately, there would be no one being trained to do abortions, there would be no one doing abortions, and voilà! -- there would be no abortions! Without the admittedly effective, but messy, need to encourage crazy people to assassinate them, as was done with Kansas physician George Tiller.

According to the Kansas City Kansan article, “Brownback mum on KU Med Center, abortion issue”,

“Gov. Sam Brownback refused to say where he stood over legislative efforts aimed at stopping Kansas University Medical Center medical residents in obstetrics-gynecology from training in abortion-related procedures. “I’m studying the issue,” Brownback said at a news conference. Abortion rights advocates, and even some legislators who have opposed abortion, say the medical residents need the training to maintain KU’s accreditation and to be able to handle emergency pregnancies. But anti-abortion advocates disagree. Brownback has signed into law several anti-abortion measures and has welcomed the Legislature’s work in this area.” Yes, he has. Funny he hasn’t yet read the one-page bill.

Of course, the biggest flaw in this logic, beyond its complete arrogance and lack of respect for women, is the assumption that eliminating officially sanctioned training of physicians in abortion would end, or even significantly decrease, the number being done. What it would do is to decrease the safety of abortions, to increase the number of women who seek and obtain “back alley” abortions. It would, quite simply, kill many women.

But the proponents of such policies and legislation seem to have no problem with that. They are, after all, not fetuses.