The Nature of Health: How America Lost, and Can Regain, a Basic Human Value

264 Pages·2016·5.901 MB·English

by  Fine, Michael, Lawrence, Robert S., Peters, James

THE NATURE T
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HOW AMERICA LOST, AND CAN REGAIN, A BASIC HUMAN VALUE
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Th is pioneering work addresses a key issue that confronts all industrialized nations: U NATURE

How do we organise healthcare services in accordance with fundamental
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in worthwhile relationships is a better, more the Foreword L
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Commissioner, The State of Rhode Island,
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clinical medicine is practiced in the United of Clinical Family Medicine, University of F
States in the early years of this new century. We Massachusetts Medical Center IN HOW AMERICA
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MICHAEL FINE JAMES W. PETERS
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The Nature of Health
How America lost, and can
regain, a basic human value
MICHAEL FINE
M.D.
and
JAMES W. PETERS
Foreword by
ROBERT S. LAWRENCE M.D.
Radcliff e Publishing
Oxford • New York
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2007 by Michael Fine and James W. Peters
CRC Press is an imprint of Taylor & Francis Group, an Informa business
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Version Date: 20160525
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contents
Foreword by Robert S. Lawrence vii
Michael Fine’s preface xi
Jim Peters’ preface xiii
About the authors xvi
Introduction xvii
PART ONE WHAT HEALTH IS NOT 1
Demented and Contracted 3
1 The health we have 9
2 The health we buy 15
3 What we measure is not health 21
4 Medications are not health 29
5 Medicine is not health either 37
6 Science is business, not health 43
Hancock County 48
PART TWO WHAT WENT WRONG AND WHY 53
The Happy Victim 54
7 The human tsunami 59
8 The reductive trap 75
9 The trap is sprung 83
10 How longevity kidnapped health 91
11 Medical services and communities 97
12 The zero-sum game 103
Three People, Three Aortas 117
PART THREE WHAT HEALTH IS 125
A. Fib 127
13 What Webster thinks 131
14 Old villages, new lives 141
15 Toward a social defi nition of health 145
16 Health and community together 151
17 Health and fairness 165
Amish Boy 169
PART FOUR WHAT’S NEXT? 173
18 Who gets what? 175
19 How should it look? 187
20 How should we pay for it? 199
21 Which doctors? 213
References 225
Bibliography 237
foreword
Th e litany of problems associated with health and healthcare in the United
States seems to lengthen each week. We Americans are just under fi ve
percent of the global population yet consume almost half of the global
health budget. We are approaching $2 trillion per year in expenditures
while leaving 15 percent of our fellow citizens without health insurance.
As the debate swirls among presidential hopefuls about how to fi x and
reform the healthcare system and the Congress prepares to appropriate
additional funds to expand SCHIP (State Children’s Health Insurance
Program), President George W. Bush says about those children without
health insurance, “I mean, people have access to health care in America.
After all, you just go to an emergency room.”1 Despite the clumsiness of
his speech and the callousness of his remarks, the President’s views are
shared by enough Americans to help explain why we remain one of the
few OECD (Organization for Economic Cooperation and Development)
countries without a health system providing universal access to healthcare.
Mexico and Turkey join us in this dubious category among the 30 member
countries. All other high and upper income countries of the OECD are in
compliance with Article 12 of the International Covenant on Economic,
Social and Cultural Rights (ICESCR), which asks that steps be taken to
create conditions “which would assure to all medical service and medical
attention in the event of sickness.”2 But I forget — the United States is also
the only OECD country not to have ratifi ed the ICESCR.
Historians, political scientists, and other scholars debate whether
our failure to ratify ICESCR (and a number of other social justice cov-
enants constituting the body of international human rights law) and to
embrace the concept of a right to health refl ects de Tocqueville’s concept
of American Exceptionalism or is a manifestation of a deep-rooted commit-
ment to American sovereignty or both. In Democracy in America Alexis
vii
viii The nature of health
de Tocqueville identifi ed the values of liberty, egalitarianism, individ-
ualism, populism, and laissez-faire as the key elements to our success as a
democratic republic.3 Notably absent from these values is a commit ment
to community or the value of social cohesion, and therein lies the dilemma
and explains how we can be so passionately committed to civil and political
rights, indeed be John Winthrop’s “City on a hill,” while tolerating with
almost pathologic indiff erence enormous inequities in health status, educa-
tional opportunity, job security, and livelihood in this, the richest country
on earth.
Murray and his colleagues documented the burden of suff ering in the
United States in a recent study of health inequalities using data aggregated
at the county level, by gender, by race/ethnicity, and by income. Th ey
noted, “Th e gap between the highest and lowest life expectancies for race-
county combinations in the United States is over 35 years. We divided the
race-county combinations of the US population into eight distinct groups,
referred to as the ‘eight Americas,’ to explore the causes of the disparities
that can inform specifi c public health intervention policies and programs.”4
Asian-American women in Bergen County, N.J., had the highest average life
expectancy in the nation at 91 years, and Native American men in several
South Dakota counties had the lowest life expectancy at 58 years. Seven
Colorado counties, two Iowa counties and Montgomery County, MD, were
tied for the highest average life expectancy at 81.3 years while six South
Dakota counties had the lowest average life expectancy at 66.6 years. At
the state level, Hawaii recorded the highest average life expectancy at 80
years, followed by Minnesota at 78.8 years. Th e District of Columbia — the
seat of our national government and often regarded as the power center of
the world — had the lowest average life expectancy at 72 years, followed
by Mississippi at 73.6 years.
Our neighbors to the north grappled with health disparities decades
before we began to pay attention. Pierre Trudeau, elected Prime Minister
of Canada in 1968, asked Marc Lalonde, Minister of Health and Welfare
from 1972–77, to chair a commission on the causes of health inequalities
and disparities among Canadians. A New Perspective on the Health of
Canadians — commonly referred to as the Lalonde report — was presented
to the House of Commons in 1974. Th e report identifi ed two objectives
for improving the health of Canadians and narrowing the gap between
the healthiest and the sickest: 1) reforming the healthcare system to
improve access to care, and 2) reducing health risk by greater attention to
prevention of health problems and promotion of good health. Th e report
also introduced the concept of “health fi elds” or the domains of infl uence
on health status that deserved attention. Th e four fi elds are healthcare
services, environment, biology, and behavior. Th e Lalonde commission
Foreword ix
concluded that differences in health promoting and health damaging
behaviors accounted for about 40 percent of the disparities in health status
among Canadians with each of the other three fi elds contributing about
20 percent. Of course, had the defi nition of environment been expanded
beyond the physical environment (“horse kicks and lightning strikes,” as
one Canadian wryly observed) to include the economic and social envi-
ron ment, then much of the diff erence in health promoting and health
damaging behavior would be linked to the environment as well. Lalonde
believed that good health was the foundation on which social programs
were built and that the healthcare system was only one of the necessary
methods to maintain and improve health. Reducing poverty, preventing
violence, protecting the environment, expanding educational opportunity,
and assuring equity became as important to increasing the health of
Canadians as improvements in the healthcare system.
In 1986, WHO convened the first International Conference on
Health Promotion in Ottawa and adopted the Ottawa Charter for Health
Promotion, defi ning health promotion as a “process of enabling people to
increase control over the determinants of health, to improve their health.”5
Th e United States was one of the participating countries in the conference
but the lessons brought home from Ottawa had no discernible impact on
health policy during the Reagan era.
So here we fi nd ourselves mired in a system that consumes an ever-
increasing share of our national income without diminishing health
disparities among our people or improving our standing in the world
ranking of healthy societies. How did we get to this place and what can
we do about it? In this book Michael Fine and James Peters present a
provocative analysis of the meaning of health and the way in which clinical
medicine is practiced in the United States in the early years of this new
century. Th ey bring their analysis to life with clinical stories about real
patients suff ering the real indignities imposed by our dysfunctional system
of clinical care and the failures of jury-rigged safety nets. Th ese stories
illustrate the historic and philosophic discussion of the meaning of health,
the illness experience, the role of social capital in health, and the challenges
to medical professionalism posed by the commodifi cation of medicine.
We Americans remain ambivalent about whether healthcare is a right or a
privilege, and this ambivalence is refl ected in our tolerance of living with
45 million of our fellow citizens uninsured while simultaneously expecting
and demanding the maximum application of life-saving and life-extending
treatments for ourselves and our families. When the authors say that
“health is the ability to have relationships, not the demand of living forever
. . . health is the love of others,” they correctly focus on the very essence
of being human. Th eir defi nition of health as “the biological, social, and