Damaged Care: What we get for our health care spending

Damaged Care: what do we get with our health care spending?

Not too far from here there was a little-known, isolated town situated on the top of a cliff on a beautiful spot overlooking the water. This town was blessed with a fine natural hot spring. People lived there happily. They knew that the spring had remarkable benefits and the local people used it and enjoyed good health. Other people came to the town from all around to enjoy the springs.

The town was set right on the edge of a high cliff top. Visitors drove to the town via the one road that headed directly to the edge of the precipitous cliff before turning into the town and resort. On occasion, a driver would not see the edge and the car would plunge over the cliff wreaking havoc to the occupants.

In recent years these car wrecks became more common and created problems. The town feared that if didn’t do something, they might lose the livelihood they had from people coming to enjoy the springs. Desperate, they assembled a committee to look into the matter who hired consultants, the best in the US, to advise them. The consultants reviewed the situation and wrote their recommendations after which the committee reached a decision, which they announced at a town meeting.

The head of the committee reviewed the problem of the road coming close to the edge of the cliff so an occasional guest car would plunge down to the bottom. The consultants had found the ideal solution. The town would build a hospital with a state of the art trauma center at the bottom of the cliff and this would solve the problem.

I want to get us thinking of a better solution this evening.

Our society is perched at the edge of a cliff. We are all in that car coming close to the edge hoping we see the road turning left into the town to avoid the plunge. We want to enjoy what the town has to offer in our quest for health. Do we want to face perilous injury and possible death and hope that the hospital and trauma center at the bottom of the cliff will put humpty dumpty back together again?

I was a graduate student in mathematics at Harvard University in the late 1960s when I became disillusioned with the impractically of pure mathematics and wanted to do something useful for society. So I went to medical school to become a doctor since there was no question that this noble profession benefited humanity. I have now been working as a doctor for almost 35 years and for thirty of those as an emergency physician. It has been a privilege to serve other people when they are most in need of help. I am very grateful for that opportunity.

For example, 30 years ago I recall a nun in Nepal when I was working in a remote Himalayan Valley who had been blind for years because of cataracts and I never saw her even though she lived nearby because she couldn’t see. Then after simple surgery, she navigated difficult terrain and we met almost every day. In the US today meningitis that was devastating in children is never seen because we have a new vaccine to prevent the Hemophilus bacteria infection. When someone comes in with a heart attack to my hospital, I can usually get him into a cath-lab to have the clogged vessel opened. For a woman incredibly distressed with a severe migraine, I can often help her leave smiling, and feeling much better. At the end of my ER shift, I can feel good that I have helped a few people. But has my profession, being a doctor providing medical care, benefited humanity? Have I made good on my goal that prompted leaving mathematics? Unfortunately not. Because everyday observations or facts about our health as a nation in the world trouble me. I want to share those with you.

The United States spends half of all the money paid in the world for health care. Yet we represent less than 5% of the population of the world. For 2005 we spent 15.6% of our very gross national product on health care, or close to $7000 per person or about $1.94 trillion dollars. Imagine the number two with 12 zeros after it? It represents a very very large number. How far would a pile of hundred dollar bills, one on top of another, reach to represent this amount. It would extend 620 miles out into space, or the height of 113 Mount Everest’s, stacked one on top of another.

That large number, two with 12 zeros after it in dollars, represents one sixth of our total economic activity in the United States. If we cut the US effort pie into six pieces, one of those six pieces is taken up with health care spending. The increase in health care costs from 2000 to 2005 amounts to 24 % of our economic growth during that period. Almost a quarter of the growth of our economy during this period was absorbed by the increase in health care costs.

This huge amount of money spent must be buying us something. But it isn’t buying us health as far as the US as a nation is concerned. During the same period our health, compared to that of other countries, declined. In 2003, there were 27 countries that were healthier than the US when considering average number of years lived. Studies show that this measure, life expectancy, is a good indicator of the health of a country. Who are the healthier countries? To begin with almost all the other rich countries, you know, Canada, Japan, Sweden, France, Germany, even Israel. Then some you would probably not consider rich, such as Greece, Costa Rica, Chile, Malta, and Singapore. We are as healthy as Cuba, the country we have been strangling for 45 years.

When I say that our health as a nation, compared to other countries, fell, I mean that by any measure of health, average number of years lived, or many others, the improvements we have been making are less than in pretty well all the other rich countries and a few poor ones, so they are becoming healthier compared to us.

In other measures of health we are even worse compared to other countries than looking at life expectancy. Consider infant mortality–what proportion of children born die in the first year of life–, maternal mortality –what proportion of women die from childbirth related causes. In those we rank at the bottom of all rich countries and a few poor ones as well. Such mortality measures are objective, since they depend on knowing only whether someone is alive or dead. We also don’t do well in measures of quality of life, where we look at various disabilities, or in measures of well being or happiness. Our happiness as a society has been declining slowly for the last 40 years with the decline greatest in women. This despite progress that even science fiction writers didn’t imagine 40 years ago. We don’t do well in measures such as deaths from childhood injury, or deaths from child abuse, or in teenage births. Our teen birth rate is twice that of the next closest rich country, We have more homicide deaths than any other rich country. There isn’t any measure of health in which we excel these days, except in spending money for health care.

We are healthier as a country than fifty years ago, but if we compare ourselves to over 25 other countries, our health improvements have lagged behind them during this period. This has happened despite incredible medical advances that enable us to do some pretty amazing treatments that most of you are aware of.

Here are two statements, which seem self-contradictory. We spend far more money than any other country on health care per capita, yet we are less healthy than the other rich countries by any measure.

This is a paradox namely that health care doesn’t seem to be buying us health. The terms health and health care sound synonymous but our story of the town at the edge of the cliff illustrate that what we do for health care may not be what is necessary to produce health.

In many other talks I’ve discussed what makes a population healthy, I point out that spending on health care doesn’t do it, nor does having more doctors, trauma centers, intensive care units, and the like. The research is clear on that. The key concept about producing health in populations, namely that once everyone’s basic needs of food, water, shelter, and security are attended to, is the way a society cares for and shares with its members. That is what impacts its health. A measure of caring and sharing is the gap between the richest and poorest in society. Populations with a smaller gap will care for and share with one another, while in a very hierarchical community the less fortunate have to fend for themselves and die younger, a concept termed health disparities or health inequalities. A leading researcher on the health of societies, Richard Wilkinson states, “inequality kills.” He writes “we should liken the injustice of health inequalities to that of a government that executed a significant proportion of its population each year without cause.” This is a form of structural violence I’ll speak about later.

The experts don’t disagree. In the Institute of Medicine’s 2003 report, THE FUTURE OF THE PUBLIC’S HEALTH IN THE 21ST CENTURY, a federal document, on page 59 they write: “more egalitarian societies (ie those with a less steep differential between the richest and the poorest) have better average health.” To look at the studies on what makes a population healthy, search for the Population Health Forum on the web.

We spend one sixth of our economy, a sixth of all output in this country, on health care, and the increase in costs over the last 5 years represents a quarter of our total economic growth, yet I’m, telling you that we don’t have a healthier population to show for it. You are spending much more money for something, and yet you have less of it. What do we have for this payment? A very profitable business; the business of providing health care. People make huge amounts of money off the spending on health care. While US corporations who provide health care to workers as part of the compensation package are complaining that the costs are eating into their profits, the corporations providing the care, the drug companies, and many other health care businesses reap huge profits. This medical care business I call Profit Care.

The United States is a nation of some very few rich people and the rest who struggle. We used to all be middle class but today we have the smallest middle class of all rich countries. Compare a family in the early 1970s when there was only one wage earner with one these days where two people need an income to survive. In the early 1970s the average family, with one worker out side the home had almost $23000 in fixed costs, the money you have to pay such as mortgage, child care, health insurance, taxes, the family car and so on) and almost $20000 of discretionary income, that you spend on what you like, such as vacations, toys for kids and for adults. In this century, your fixed costs, what you have to spend money on, with two wage earners amounts to over $55,000 while the money you get to play with is less, only $18,000. No wonder a quarter of Americans don’t take vacations. Therein lies the reason for our deteriorating health.

After my medical training I started out working in a remote Himalayan valley in Nepal, a week’s walk from the road where we treated the blind nun I mentioned earlier. I taught local people about treating medical problems in that setting and improvised as best I could. I could tell you some heroic success stories and some dismal failures. What I learned was how relatively healthy people could be without any medical services once they survived early childhood. Without medical care, once we are past the early years, we just don’t all drop dead.

I came back to this country and have practiced emergency medicine during the last 30 years with long stints back in Nepal during that period. I have also worked in rural British Columbia, and as an assistant county health officer in Washington State. I’ve taken care of stabbings and shootings, of vehicular crashes, heart attacks and overdoses, the bread and butter of emergency medicine in this country. I’ve also spent years in Nepal setting up remote district hospitals as teaching hospitals and facilitating learning to improvise in those environments. I’ve taught clinical medicine in the US and Nepal, and continue to teach in the public health school at the University of Washington. I’ve been in many trenches. So why did I come to question the good that medical care does?

It began in medical school at Stanford University when I discovered that the US was not the healthiest country in the world. Back in the early 1970s, it wasn’t even in the top ten. Around 1950 we could claim to be one of the five healthiest countries in the world, but that hasn’t been true for over half a century. At Stanford back in the early 1970s they were perfecting heart transplant surgery. Watching one of these procedures was heady stuff and taking care of transplant recipients as a medical student was exciting. I didn’t think we were carrying out the surgery at the bottom of a cliff back then. Still, I couldn’t explain why we weren’t so healthy as a country.

By the 1980s after 15 years of being a doctor, I learned that our health had declined further so now there were almost 20 countries healthier than we were. I began to question the role of medical care to produce health in a nation.

By the early 1990s I was ever more aware that medical care could cause harm. I had seen how sometimes mistakes happened and how some people treated in the health care system did poorly. Even if mistakes didn’t happen, some people might be worse off for having received medical care.

I had almost certainly harmed my patients on occasion, and I saw that patients had been harmed by others providing health care. Except for the publication of Ivan Illich’s polemic Medical Nemesis back in 1976, there was no popular coverage of the concept of iatrogenesis, to use Illich’s term for harm. I came across the first systematic study of medical harm done by a team from Harvard University who reported in 1991 in the prestigious New England Journal of Medicine on their look at harm occurring in New York State hospitals in 1984. They found adverse events from medical care were pretty common, almost 4% of admissions. In over 13% of those, death occurred that might not have occurred without medical care. Extrapolating from those rates to the nation as a whole, they found there might have been somewhere between 75000 to 150000 deaths a year occurring in US in hospitals from medical care.

It took two more such statewide studies in Utah and Colorado, to verify that the numbers were correct. Half of the deaths due to medical harm were from mistakes, errors, and negligence, depending on the term used. The other half were just the nature of the medical care beast, namely people were harmed by medical care done right. In 2000 the federal body, the Institute of Medicine published its report, TO ERR IS HUMAN in which they wrote that between 44,000 and 98,000 people a year die in hospitals from medical errors. The report didn’t look at the other half of medical harm, namely people being injured by medical care without a mistake being made.

If you are willing to consider that medical care can be a leading killer, how can you find out if this is true or not? I challenge my students this way all the time. I’ve already mentioned figures and data presented by our federal government. We know they can mislead, but usually it would be in the opposite direction from saying so many people die in hospitals from mistakes. Barbara Starfield, a leading researcher and medical doctor at Johns Hopkins University, which houses arguably the best medical school in the country writes in the November/December 2005 issue of Boston Review: ” several studies have shown that the third leading cause of death in the United States, after heart disease and cancer, is medical intervention, including both tests and therapies. Over the past few years, the annual number of reports of adverse effects from prescribed medications (including deaths) has been increasing. A conservative estimate of the percentage of deaths in the United States that result from adverse effects of medical treatment is ten percent. In other words, an estimated 275,000 of the total of 2.5 million deaths that are annually attributed to specific diseases are really a result of harm from interventions. ” That number of deaths due to medical care, 275,000 a year is roughly equivalent to a September 11, 2001 tragedy occurring every 4 days. The harm inflicted by medical care in the US can be compared to a continuous terrorist tragedy, except that there are no planes flying into buildings, and no bodies burning. The process is almost invisible and never discussed. There are no reprisals; there are no invasions of other countries. Structural violence is the term used to describe such apparently invisible phenomena, as opposed to violence that is behavioral where there is an assailant, a smoking gun and visible trauma.

Medical care is a leading cause of death. Our newsmagazines and other sources will hide this within articles, but if you look closely, you’ll find estimates saying medical care is among the top ten causes of death, where they look only at mistakes in hospitals. Dr. Starfield pointed out a higher figure by looking at the bigger picture.

The critical issue was not the mistakes made. There are ways to improve those numbers. I want to focus on the other half; medical care done right that kills. Harm from medical care that is practiced as it’s supposed to be done is as common as harm from the mistakes.

Here are some true stories -not from my practice as a doctor- there are many of those, both from the US and abroad, but from being just an ordinary person .

My sister-in-law had a tumor in her liver. She taught school on Thursday and went to a hospital rated in the top ten in the US for surgery the next day. She bled to death on the operating table. It was not due to a mistake but to a technical complication in which a medical device, a stapler, failed. Had she not had the surgery, she would likely still be here today. My next-door neighbor had a similar situation just this past year when he went in for liver surgery in a top ten hospital for a tumor and died after a prolonged ICU stay from liver failure. Bad outcomes can result from the work good doctors do.

In the 1950s a 15-year-old boy had a patch of acne below his right ear. He didn’t like it so his mother took him to see a dermatologist who said: “that’s no problem, we’ll just radiate it.” This boy would come to the doctor’s office for weekly treatments where an X ray beam would be focused on his patch of acne, while he wore lead shields over his eyes. The treatments were painless and effective. In less than a month, the acne disappeared. Everyone was delighted. Some 18 years later a lump appeared deep in the tissues where the acne had been. It turned out to be a lymph gland cancer or lymphoma. We now know that treating acne with radiation is not good for people. But in the 1950s that is how localized acne was treated.

So medical care can do something that is, at the time, the state of the art treatment, and later it may be found to be harmful. Consider hormone replacement therapy for women, which we all agreed was the right thing to do when I was in medical school, but now we know it kills more people than it helps. The class of pain medicines known as Cox-2 inhibitors typified by Vioxx is another example where no one thought that they would kill people until studies demonstrated that Vioxx did kill although as you might expect, Merck, the richest pharmaceutical company in the world and the producer of this drug, has never published those but withdrew the drug from production. I recall my professor of medicine beginning a lecture 33 years ago saying that “in ten years time you will find that half of what I am telling you is wrong, I just don’t know which half.” We want to believe that in medical science what we say we know is in fact truth. But this does not appear to be the case.

If you find this evidence troubling, namely bad outcomes from medical care where no mistakes are made, ask around. I was in State College, PA talking to a premedical student class in the fall about their future careers. In such situations I often ask for stories from students about themselves or family members who have been helped by medical care. I was startled to not get any responses from them. I then asked for examples of harm and was deluged by sad stories of deaths happening to fathers and best friends from various circumstances. So I urge you to ask around and you’ll find that if you don’t have personal experience of medical harm among family, there will be several from friends.

We have studies of medical harm in six countries. They all look at hospital records and find similar rates with mistakes making up half of the harm in causing death. There are no systematic studies on medical harm occurring outside of hospitals, but since most people die away from hospitals and have had medical care, any estimates we come up with from the hospital data will fall far short of the true figure.

Medical care is not listed as a cause of death on any death certificate I know of, the death is due to exsanguination, as in the case of my sister-in-law, or liver failure as with my next-door neighbor. Counting up the numbers of people harmed by health care is difficult. But the carnage is huge. When such research on medical harm is published, it becomes news but only when the study comes out. Soon the issue is forgotten as the next horrible tragedy is featured.

Who complains the most when doctors go on strike? The morbid truth is that the morticians or undertakers have less work to do. If medical care was saving lives, then surely death rates would go up. But research shows the opposite. One in the US has been systematically studied, there are two reports in Israel and one in Colombia all consistent with death rates dropping when doctors don’t work. This is grim reaping. If the airline industry had a safety record like that of medical care, we’d all be walking.

I’m not am saying that medical care doesn’t do any good, that we should abandon it. I studied hard to pass my emergency medicine recertifying exams last year so the authorities can be sure that I can continue to work as a competent ER doc. Medical care can do good, and very often does. But we have to find a balance to use medical care for the good it does and to try to limit the harm. There are no studies demonstrating that what we call medical care, both preventive and curative, unequivocally, benefits whole populations.

If we go to an esteemed reference, THE OXFORD TEXTBOOK OF PUBLIC HEATLH, in a multi-authored three volume 2002 tome, in the chapter entitled ” Medical care and public health” in the conclusion it states: “The impact of personal medical services on the health and survival of individuals seems readily apparent. With modern investigations and treatments, patients are now regularly saved and make very good recoveries from infections, injuries, and a variety of other conditions that were almost uniformly fatal even a few years ago. Surprisingly it is more difficult to demonstrate conclusively the impact of these medical advances on the health of whole communities.” We can all attest to the good that medical care has done to our family and friends. But researchers can’t demonstrate the impact of medical advances on the health of whole communities. We hope there is some benefit, but to spend an entire sixth of our huge economy on health care and not ask whether it benefits our nation’s health is foolhardy.

In my career as an ER doc, I’ve faced the entire range of complaints from “I’ve just overdosed on some pills” to “I’m not happy.” I can probably do something lifesaving for the first person, but there is likely little I can do for the unhappy patient. Whereas I could prescribe a happy pill, the anti-depressants commonly used today, in some people, these happy pills increase the risk of suicide and have other side effects such as sexual difficulties. In our society we are medicalizing various feeling and emotional states in order to treat them with drugs that themselves can kill.

Psychiatrist Thomas Szasz suggested that just as “theocracy is rule by God or priests, and democracy is rule by the people or the majority, so pharmacracy is rule by medicine or physicians.” I sometimes call myself an MDeity. Such is the society we have in the USA, where pharmaceutical corporations, for example, have found a way to very profitably rule us through the health care industry, which represents both profit care and as we have seen, damaged care.

The motto “don’t just stand there, do something” should be turned around to be “don’t just do something, stand there” unless it is really clear that doing something will help and there isn’t much chance of harm.

Thomas Pynchon wrote in Gravity’s Rainbow “If they can get you asking the wrong questions, they don’t have to worry about answers.” and for much of my career as a doctor, I asked the wrong questions. For example asking what screening program would be best for trying to find out who has heart disease or breast cancer, or prostate cancer, for example. Instead consider if there is evidence that screening is beneficial. In most diseases there isn’t and in some screening has been proven to increase mortality!

One could ask the question “is there a part of medical care that might work?” In other words, is less more? Research by Dr. Barbara Starfield whom I mentioned earlier, and her colleagues Leiyu Shi, and James Macinko at Johns Hopkins University demonstrate that populations that focus on primary care over specialty care may have the beneficial part of health care. Studies in the US demonstrate that those states focusing on primary care have better health outcomes than those with a preponderance of specialists. The same is true among rich countries studied. In much healthier Canada, the bulk of their medical workforce are primary care providers, with only a small fraction of specialists, whereas in the US the reverse is true.

Why? Primary care providers, people like family doctors, GP’s in Canada and Britain, nurse practitioners, physician’s assistants, can take care of the bulk of sick people’s problems. They are perhaps less likely to do aggressive care, the kind that might be more harmful. They are more apt to spend time with patients, hold their hands, support them, and perhaps even make house calls! The key elements of primary care are ease of access, which includes physical location, and hours of operation, and having enough time to spend with patients. And primary care costs much less.

Think instead of how the practice of health care has morphed. Medicine has become very technological lately with the ordering of expensive tests and the performing of various procedures by specialists the norm. Gastroenterologists, or gut doctors, are taught that there are one or two thousand-dollar bills in every American colon. They just have to get their scope up there and remove them. While this may be very profitable for the doctors and the health care businesses that employ them, it may not be in our best health interests. Once the thousand dollar bills are plucked out, not unsurprisingly they reappear there in a year or more, ready to be fished out again. Becoming a gut doctor might be seen as a perfect way to have a substantial steady income, pocketing those thousand dollar bills from your patients every few years.

There can be too much testing and doing too many unnecessary procedures that may by themselves cause harm and kill let alone cost a great deal. If you think you are healthy, you haven’t had enough tests yet. With modern diagnostic technology we can discover something to label a disease in practically everyone alive. Have we done our patient a favor by doing this? No, we’ve made them worry, and want more tests and procedures, which can lead to harm from overuse of medical care. Again, I’m not saying tests and procedures have no value; it is just that they can lead to other problems.

When I’ve worked in the ER’s of high tech specialty hospitals, I see patients checking in to the ER after they’ve been to a bevy of specialists there. One such hospital in Seattle attracts many patients from Alaska who think the care is better there. A typical example would be someone who has been weak and dizzy for six months. They go to the neurologist, have a bunch of tests and the doctor says it isn’t your nervous system. They go to an Ear Nose and Throat specialist who tells them that it isn’t their organ (the vestibular system) that is responsible. The cardiologist says the same thing, it isn’t their heart. And the gastroenterologist has endoscoped the patient from both ends, pocketed several thousand-dollar bills, and pronounced that the gut is fine. Each expert told the patient that his or her problem was not about the organ system that the doctor treated. Then the sad person is in front of me distraught about what to do. Often just listening to their story helps a great deal. I empathize, I review what has happened, and I try to fit it into some perspective that is acceptable to the patient. Sometimes they ask me if I have a practice outside the ER so they can come and see me again. This is the ultimate complement for an ER doc. Alas, I don’t.

We started out confronting that we spend a huge amount of money on health care, yet we don’t seem to be that healthy, at least in comparison to people in other rich countries and some poor ones as well. We are about as healthy as Cuba. Cuba has lots of doctors, but no fancy technology and their doctors don’t make huge salaries. They spend time with their patients, they massage them, and they make house calls. Cuba spends a pittance on health care and even less in recent years. There are only 3 countries in the Americas, Canada, Costa Rica and Chile, that are be healthier than the US and Cuba.

Health and health care cannot be synonymous. The health of a country refers to measures of its well-being, its mortality, and other outcomes of human welfare. Health outcomes must be compared to other countries to see how well a country is doing. We in the US are healthier than Swaziland and starving Malawi in Africa, but that should not be the standard to which we hold ourselves accountable, especially being the richest and most powerful country in history with half of the world’s billionaires. We used to be one of the world’s healthiest countries 55 years ago, but we are far from that now. If we eradicated heart disease as a cause of death, if we won the war on heart disease, we still wouldn’t be the healthiest country in the world. No doctor considers it possible to eradicate heart disease through medical care. But that is how much healthier other countries are compared to we the people in the USA. We die much younger than we should in the United States.

Health care is like building the trauma center at the bottom of the valley to take care of those who careen off the upper cliff. At best the hospital can only pick up the pieces of humpty dumpty and try to put them together again. Some of that it does well, but some of what it does harms and Humpty cracks apart.

In training to become a physician, I have been indoctrinated towards treating disease. In US medical schools, there is little discussion of health. We are told that public health tries to do primary prevention, or preventing the occurrence of disease. But we doctors are not taught about producing health. The best we can do is to try to prevent disease which represents a very different way of thinking. Societies that are healthier than the US recognize the need to focus on health rather than on disease. They structure the country so that health naturally occurs, and health care is not considered as important in that process as it is here. Other nations recognize that individual behaviors are not as important in producing health as creating social and economic justice in societies which, by themselves produce good health. As a doctor I thought I was doing my job to prevent disease by telling people to eat right, to exercise, to not smoke, to wear their seat belts, to use a condom and to see your doctor. That is good advice, but it isn’t so important in producing health. Consider Japan, the healthiest country in the world. Japan has a higher percentage of men who smoke than any other rich country. Yet Japanese men live the longest of any country in the world, despite smoking twice as much as we do. That isn’t the reason that Japan is so healthy. Factors other than behaviors such as not smoking that we consider very important in this country are more important in producing health.

The rules governing society that decide who gets what share of the resource pie are more important than individual health-related behaviors, just as our Institute of Medicine says when it states “more egalitarian societies have better average health.” Instead in the USA through our political process we have managed to create so much inequality, that is we have the most unequal society among rich countries, and people do not complain of this managed inequality. Our system is very successful in taking care of the wealth needs of the rich and powerful, but not their health needs and the link between inequality and poorer health for all is not widely understood.

For the USA to become healthy again, compared to other countries, will require that we begin to see that our economic policies are the most important health policies we have. When we create a society that takes from the poor and gives to the rich, as our Hood Robins are doing, by tax cuts for the rich, and by subsidies to rich corporations, and by waging wars for profit of a few, while at the same time, neglecting the poor in this country and having those poor blame themselves for their having low incomes, we will have less good health. We need to stop this managed care system of dying young.

Geoffrey Rose, a famous British scholar in prevention concluded his 1992 monograph, THE STRATEGY OF PREVENTIVE MEDICINE, with these two sentences: “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.”

We in the US should not blame our damaged care non-system of health-care for our poor health. We should blame ourselves for not being aware of what produces health in society and for allowing the changes that have occurred in this country over the last few decades that have created immense wealth, almost unbelievable wealth, for a few, and at the same time creating more and more poverty and especially more relative poverty measured as the height of the cliff between the rich and the poor. It is that gap between the rich and the poor that is responsible for our poor health status as a country. Even the feds agree as they stated in asserting that more egalitarian societies have better average health. The gap between the have too little and the have way too much’s has increased drastically over the last ten or twenty years. Comparing our poverty rates with those in other rich countries is shameful. We have the most child poverty, for example, of all rich countries. If we can’t provide for our children, if we can’t provide for their parents, then we all pay the price with shortened lives. If we don’t take care of others, then our own health suffers. That is what the research shows. The rich would be healthier being less rich in a smaller gap society. We’d all be better off with less poverty in our faces.

I have pointed out the problems with health care, namely that it harms as well as it helps. I haven’t tried to present a solution for producing health that focuses on health care. No matter what we do with our damaged health care, it won’t do that much to our health. It is tragic to live in the only rich country without universal access to health care. The uninsured certainly want access to medical care. And they should have access as a basic human right. We already spend more government money at the federal, state and local level on health care per capita than any other country spends in total on health services per capita yet we have more than 45 million people without medical insurance coverage. So without spending a penny more for health care, just by restructuring the system, we could provide medical care for all. But we would have to change our profit care approach.

Consider halving the amount of money we spend on health care to be more in line with other rich countries, and in removing the profit motive from medicine. Workers should all be salaried and everything would be rationed, based on using the best available estimates of effectiveness. We should focus on primary rather than specialty care. We should do less health care but what we do should be available to all people. But that is difficult for most of us to comprehend as being good for us, let alone take seriously. I don’t spend my energy working on changing the health care system in the US. I work for health, not for health care, though I work in health care. It is my day or night job. Providing emergency services is important work, but talking to you may be even better in producing a healthier society.

We should be close to the Gold Medal in the Health Olympics instead of coming in 28th place today. We always win the most gold medals in the Olympic games. The winter games are beginning in Turin, Italy in a few days. We have had the most overall medals, and gold medals in the Olympics. We have won the most Nobel prizes of any country. We have far and away the most billionaires among nations in the world. We should be the healthiest but we are not because we don’t demand to be.

Producing health in the US is much easier than reforming the health care industry. We can begin by overturning most of the recent legislation that gives more to the rich. The tax cuts, personal and corporate, the attempt to kill the estate tax, the subsidies to corporations of unfathomable amounts. We can go back to policies we used to have when we were one of the healthiest countries in the world. Tax and subsidy policy is health policy. Higher taxes for the rich, significant corporate taxation, decreasing subsidies to the rich and instead subsidizing the poor, promoting fair trade policies, these are all health policies.

Our current obsession with welfare for the rich doesn’t have to be that way. Consider that a republican president proposed a guaranteed income in 1969. A democratic president proposed a maximum wage for the US in 1942. We used to have a Robin Hood mentality when we were much healthier than other countries and we would all benefit with a return to those values today.

As a medical doctor, because of what I have said I am not telling you to avoid doctors and the health care system, especially if you are sick. I see doctors when I am sick. For many conditions medical care can very helpful.

To deal with the health care arena, sort of like being in the lion’s den, seek out a doctor, or nurse practitioner, or physician’s assistant, some health care worker, with clinical judgment who doesn’t believe in overkill. Find such a person when you are well. Deciding whether or not this person has what I call clinical judgment is not easy. It is someone who will take care of you, with your interests at heart, who does not see thousand dollar bills sitting up there in your organs needing to be removed every few years. Someone competent, whom you trust and who will be there when you are sick. This is not easy to do in the USA. Many people only seek out a doctor when they get sick. There is nothing wrong with that except that your care may be compromised because of the big money lying within you waiting to be extracted by the most common procedure done in this country, a cashectomy or the removal of a patient’s money.

If you end up in my ER when I’m on duty, I will provide a high standard of medical care. I will examine and treat you as a competent doctor. What I am asking you to consider tonight is to avoid too much medical care, especially the kind that may not help. It is difficult for most of us to discriminate between what might be beneficial and what constitutes too much and is the wrong sort for dealing with the sickness. That is a dilemma..

As doctors we try to treat conditions that result from living in our very stressful country when we medicalize what are not diseases such as unhappiness but are often caused by the stress of today’s workaholic and consumer culture. Those working in health care, and the rest of us must treat society as well as individuals or we are bound to succumb. Caring and sharing must become the norm in the United States.

Outside a building at the Oregon Health Sciences University is a stone with the following statement by Daniel Boostin chiseled on it: “the obstacle to discovery is the illusion of knowledge.” The illusion of knowing, that is by conflating health and health care, thinking they mean the same thing, is the obstacle to discovering what produces health in a population. The illiterate of this century won’t be those who can’t read or write, but those who cannot learn, unlearn and relearn.

If health is important for you, if the health of your unborn children or grandchildren is important to you, then you may have to unlearn and relearn.

The next difficult part is to work for producing health in the USA by creating a more egalitarian structure. It can’t depend on people’s charity; it must depend on solidarity which means we must work together. We must all work together for the benefit of all of us. Even in the best of circumstances with the most effective health care attainable, we will still be facing that concept that Rose talked about, namely that the determinants of health are economic and social and therefore we need to work in the political arena to produce health. Political policies are first and foremost health policies.

Many of us have become disillusioned with the political process in this country. Corporate lobbying forces, especially health care corporations buy the best politicians to look out for their bottom line and we are stuck at the bottom in health. But if we all understood, if the corporate lobbyists understood, if the rich understood, that our health is made worse by this process, we will have come a long way towards becoming healthy again. Notice I said that all of our health is made worse, even the rich. Does that mean they would be healthier being less rich in a just society? Yes.

It may take a long time to understand these research results. It could take a year or more of reflection to believe. If you agree that creating awareness of what produces health in populations is the critical next step, what might you do? Sending a donation to some organization that wants to improve health – not access to health care, but to improve health – in the USA won’t do it. I know of no organization accepting money for the cause of improving our health in comparison to other countries. The federal government has no such goal to make us healthy in comparison with other nations. There is a Center for Disease Control Healthy People 2010 initiative that has specific disease and behavior-related goals that extends the one we didn’t achieve in Healthy People 2000 and that we will not achieve in 4 more years. Our national goals don’t consider where we stand compared to other countries, because doing something to change that would make the challenge even more daunting.

There is something more exciting going on at the state level, with a campaign in Washington State by the Washington Health Foundation to make Washington the healthiest state in the nation. Washington stands 15th in this list, and Minnesota is number one. The Washington Health Foundation seeks to get that state to capture the number one slot and on a yearly basis we can determine if we are making progress towards that goal.

Our Population Health Forum at the University of Washington’s goal is to create awareness of the poor health status of we in the USA compared to other countries. We have never had a penny to spend, and are entirely run by volunteers. Please join us.

You can’t buy good health for the US. You can’t even spend money for this cause. That is a critical idea for the individualist charitable giving citizens of this country. You have to cause the situation to change. You need to focus on solidarity, not charity. You have to work with others to talk about these ideas and create awareness. Teach others what you have chosen to learn. How are you going to do that?

In my courses that I teach at the University of Washington, to both undergraduate and graduate students, I get them to become activists, at least for a third of their grade. I don’t tell my students what to do, for I believe that each of us has interests and abilities that can help spread awareness of what produces health among the people. Some students with graphic skills have produced good posters and printed materials such as brochures. A few students have written songs about population health and performed them. Others give talks to various groups. Former teachers have developed school curriculums. One undergraduate speaks to young republicans on campus. One student organized a game that brought many of these concepts home. If there is something like this that you enjoy doing, and have requisite skills to do, then it is more likely that you will continue these efforts for a long time. That is what activism implies, being active not just for a day, or a month or a year, but for a lifetime. It has taken this country a half century to become this unhealthy; it might take as long to get back to being one of the healthiest in the world. Far better yet would be for all nations to have comparable health outcomes. To not have this as an attainable goal is to invite comparisons with policies producing genocide.

I am talking about becoming a health activist, which by the nature of what produces health means being an economic justice activist. The work is inherently political. You can’t get out of that. It is not about partisan politics, it is about health politics, trying to get public officials and politicians aware of what produces health. If you and I know what produces health, then our officials and politicians can learn from we the people so the most effective strategy might be to get at the current politicians last. Go to the people first.

One of my more difficult challenges is talking to those who advocate for universal access to health care as the population health panacea the magic policy that would make our country healthy. Unfortunately the research does not support this. I quote from a 2006 volume published by Oxford University Press, entitled Healthier Societies, Chapter 5, titled Universal Medical Care and Health Inequalities: right objectives, insufficient tools. The last paragraph of that chapter, studying the situation in Manitoba, Canada, reads: “a universal health care system is definitely the right policy tool for delivering care to those in need, and for this it must be respected and supported. However, investments in health care should never be confused with, or sold as, policies whose primary intent is to improve population health or to reduce inequalities in health. Claims to that effect are misleading at best, dangerous and highly wasteful at worst.”

If you are an advocate for universal health care, by all means continue your work. If you advocate for increased access to health care for disadvantaged groups, they will be grateful. But broaden your focus to consider health in addition and point out the difference between health and health care.

If you are a health care worker, such as I am, then talk to your colleagues, your nurses, medical assistants, paramedics, and the clerical staff about these ideas. When I go and speak in clinics and the like, it is often the non-professionals, ordinary folk, who are most interested in these ideas and who understand them. They are your allies. Work with them.

I started out with a story about a town with springs that provided good health. There were problems, namely the hazardous cliffs nearby that killed increasing numbers. The US represents the town with the health-providing spring. This country has the capacity to produce phenomenal health in its people as demonstrated by being one of the healthiest countries in the world some 55 years ago. Instead of building a retaining wall along the roadway so that people don’t get flung off the rim to their deaths, today we have focused on building a hospital and trauma center at the bottom of the cliff, the precipice that represents that gap between the rich and the poor, which is the pre-eminent health hazard in this country. To produce health in this country, we need an economic-political guardrail, which would be the medicine that Professor Rose suggested. You may recall that I said the road turned left to enter the town. The direction is of course consistent with politics that represent social and economic justice. Enough of us need to turn left to get back to healthy political policies that we once had in this country.

You must now come to your own conclusions about what matters, about what is important. You must learn, unlearn and relearn.

When you do this, at first you will find that there won’t be many who think of population health this way and you may feel dismayed for being such a small force in the US. If you think you are too small to be effective, then you’ve never been in bed with a mosquito hovering. This is how we must begin, by hovering over those who profit from health care as they sleep and make our incessant buzz for health. We must feed the poor and eat the rich! “There is an epidemic of health care invading us. It is not good for our health. We need to work together, in solidarity, to produce health through economic justice. Don’t be missing in action!

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