December 9, 2022
Dear Interested Readers,
Political Determinants of Health
The 2022 election season is over! At least we thought it was over before Kyrsten Sinema announced that she was leaving the Democratic Party to become an Independent. It does seem that she will caucus with Democrats as do Bernie Sanders and Angus King, but you can never tell for sure what Senator Sinema will do. It did not turn out to be the disaster for Democrats that some pundits had predicted. The Democrats gained a seat in the Senate thanks to the subpar candidates that Donald Trump got nominated in Arizona, Georgia, New Hampshire, and Pennsylvania. The fact that it was not a disaster does not mean it was a victory. I fear that we are doomed to two years of divided government when it will be unlikely for any legislation that might improve the social determinants of health, gun control, or the environment to pass through a Republican-controlled House. Some say there is a small possibility of some immigration reform legislation passing.
The good news is that the Democrats will be able to get judicial appointments approved in the Senate and block the impeachments that radical right Republicans in the House threaten. The reality is that the 2024 election cycle has already begun, and the next two years are likely to be dominated by the continuing controversies surrounding Donald Trump. Narcissists are always center stage until everyone ignores them, and there are just enough people in “red America” who seem unable to look away from Trump to prevent him from going away. The only hopes we have that he will not be continuing to distort American politics for at least another two years come from the justice depart, the legal systems in New York and Georgia, or the hand of God. I fear that indictment for one of his many crimes in and out of office might be a perversion of Uncle Remus’s old “briar patch” story into which Br’er Rabbit and Trump would both love to be tossed. It is likely that he would still be a distorting force if he were in jail, but it would prove that no one is above some aspect of the law.
Now is a time for reflection. I am delighted that we no longer need to consider which is worse a werewolf or a vampire. It is also a relief that we have been able to isolate the disease of “election denial” to Arizona. The bigger question for me following the election is how despite averting a “red wave” Democrats will be able to make any progress over the next two years on the persistent problems in healthcare access and delivery. An even greater challenge is how in an era of divided government we might reduce social inequities and the associated challenges that we lump together as the social determinants of health which as Joe Knowles suggests is a euphemism for poverty.
This week Ezra Klein hosted an interesting podcast conversation with Professor Jake Grumbach, a political scientist at the University of Washington, who has recently written a book entitled Laboratories Against Democracy: How National Parties Transformed State Politics. The review of the book and the conversation Klein had with the author suggested that when nothing is possible at the national level, the Constitution and the recent decisions of the Supreme Court force issues of policy down to the state level and that often leads to “anti-democratic outcomes.”
We have seen that happen in the aftermath of the Supreme Court decisions regarding the ACA, the repeal of Roe, and decisions like Citizens United v. the Federal Election Commission and Shelby v. Holder. Grumbach and Klein remind us that the Federalists who influenced the Constitution and even famous jurists like Louis Brandeis thought that better decisions could be made closer to the point of impact at the local level. Brandeis went so far as to envision the states as “‘laboratories of democracy,’ where new policies could be incubated, tested, and spread to other states.” What is happening now may suggest that Brandeis was half right. The states are laboratories, but not for democratic ideas, rather they are producing ideas that threaten democracy and promote illiberalism. What is being produced in those “local labs” in many red states are new ways to limit voting rights, distort the curriculum in schools, force the views of the religious right through “culture wars,” and advance inequity by favoring corporate interests with deregulation of businesses, right to work legislation that undermines union strength, and tax policies that favor the wealthy.
A prime Lean concept is that the best decisions are made by the person closest to the customer or the point of production. What Grumbach suggests is that when it comes to policies that promote democracy the state and local point of contact has been perverted by a very well-constructed anti-democratic strategy. My take on the conversation was that Grumbach’s quantitative data and qualitative observations are correct in “red states” where the legislature, executive branch, and state judiciary are controlled by something like a “MAGA political philosophy.” Brandeis’s positive view of local politics has indeed been perverted. I offer Texas and Florida as examples.
The conversation was cautionary and there is hope for a reversal of the trend. Michigan is a source of hope because voters there did flip the control of the legislature from red to blue and did maintain a Democratic governor’s office. In Wisconsin, Arizona, Pennsylvania, and Georgia some of the election outcomes have defended democracy. The Klein-Grumbach conversation about the interplay of state and federal government gave me some hope even as they saw the trend promoted by the conservative Supreme Court as dangerous because some of the slim victories of the past in healthcare began as experiments within states. I offer New York’s passage of a pro-abortion bill in 1972 and “Romneycare” in Massachusetts in 2006 as examples of states performing as “learning labs” in the effort to improve healthcare.
In last week’s letter, I referenced the article by Eric Reinhardt, MD entitled “Medicine for the People” where he emphasized the concept of “the political determinants of health” which was a call to action for physicians. Reinhardt began by making reference to the behavior of physicians in colonial Algeria. That seems far away in time and place. Perhaps it was his way of reducing the sting of his accusations. He wrote:
When psychiatrist Frantz Fanon reflected on the role of doctors during the Algerian struggle for liberation in his 1959 essay “Medicine and Colonialism,” he emphasized the consequences of physicians’ class interests. More bluntly put, he tore into the colonizing complicities of his ostensibly humanistic profession.
Although the physician presents himself as “the doctor who heals the wounds of humanity,” Fanon writes, he is in reality “an integral part of colonization, of domination, of exploitation.” Both the European colonial physician and the native Algerian physician are “economically interested in the maintenance of colonial oppression,” which yields them profit and elevated status. One of the chief services doctors provide to the perpetuation of oppressive systems, Fanon notes, is the use of scientific objectivity to obscure the role of politics in driving the sickness and death they dutifully treat and then bury in medical statistics.
Are Fanon’s criticisms of medicine’s complicity with politically structured violence relevant today for those of us working in the world’s richest health system?
That introduction took my breath away. I immediately began to ask that question of my own motivations and actions over a long career. The best I could do was a half honest, “I guess at times that has been true.” His effort to induce guilt and self-evaluation continues:
…everyday life in the United States is also built on enduring systems of segregation and domination enforced by inequalities in policing, incarceration, education, economic opportunity, housing, and health care, driving thousands of preventable deaths each year. And as has been made especially clear during COVID-19, the U.S. economy has long operated by treating low-paid workers as expendable. Alongside these conditions, American physicians enjoy distinctive status and economic privileges, including highest-in-the-world physician incomes that are, on average, almost ten times greater than those of their patients.
Those words were published in March 2021. In retrospect, the Biden-introduced legislation, Build Back Better, had it passed, might have been a good example of using political power to improve the social determinants of health. Build Back Better would not have fixed everything, but it would have been a political improvement to the social determinants of health for tens of millions of Americans. It would have fostered a huge improvement in the lifelong health opportunities of many millions of children, and it also would have improved the existence of many elderly Americans. It was a missed opportunity that was not meant to be thanks to the opposition of Senators Joe Manchin and Kyrsten Sinema and all Republicans. My greatest hope for this last election was that Tim Ryan might have beaten J.D. Vance in Ohio which would have given the Democrats enough votes in the Senate to defang Manchin and Sinema. The Ohio Senate election is the one contest where Trump probably had an impact by getting Vance through the primary.
I must admit that other than writing a supportive point of view in these notes, I didn’t do anything that might have boosted the opportunity for the passage of Build Back Better. That was not true in 2009 and early 2010 when the passage of the ACA was being considered. At that time I made several trips to Washington along with other healthcare leaders to advocate for a more robust ACA than was eventually passed. I was in several face-to-face meetings with the staffs of Ted Kennedy and Nancy Pelosi and met personally with John Kerry and Max Baucus who was the chairman of the Senate Finance Committee where much of the work on the ACA was done. I don’t know of any organized effort by healthcare professionals in support of Build Back Better. But back to the scolding and the possibility of improvement offered by Dr. Reinhardt in early 2021. [I have done some bolding for emphasis.]
Although they treat the sequelae of poverty every day, doctors in the United States have historically failed to use their collective influence to address political etiologies of disease. Now, for the last year, the pandemic has preyed on America’s racial and economic inequalities. This reality has awakened many more doctors to the political determinants of health—the fact that health is not just about health care and is inseparable from power and political struggle. It has also fractured the traditional medical objectivity that records politics as biological misfortune. During the pandemic, calls for equity, justice, and decolonization have grown louder within health care, echoing traditions of social medicine that have long been relegated to the fringes of American medicine.
Reinhardt was writing before the death of Build Back Better. Unfortunately, the calls he speaks of were muted and have now become muffled or non-existent. Sure, there were a few positive healthcare offerings in the greatly slimmed-down version of Build Back Better that got passed as The Inflation Reduction Act of 2022, but the compromise bill that Manchin accepted left out most of the programs that had a chance to broadly improve the social determinants of health. Now a second swing at that ball must wait until at least 2025 because the Republicans control the House by a slim margin of 221 to 213 with one seat undecided, and it is highly unlikely that any legislation that might improve poverty and healthcare would ever be considered, much less passed.
Reinhardt asks a critical question for us to consider, especially if we are going to move the efforts to improve the social determinants of health down from an exercise in national policy to the state and local level and explore what we might accomplish in those states where democracy and a broader concern for the underserved still exist with enough public support to have a chance to test policies that might improve the health of disadvantaged populations. Reinhardt wonders if American healthcare professionals really care enough about the inequalities in healthcare and the broader social issues that determine health to make political efforts to improve the lot of their most disadvantaged patients.
Reinhardt uses Paul Farmer as an example of a physician who made a difference in the effort to improve the social determinants of health by living and being among the disadvantaged. My take on his presentation is that at a minimum, we must, like Farmer, have tremendous empathy that approaches what some might call “fellow feeling” if we are going to make a difference and be successful in our efforts to improve the social determinants of health. Farmer talked about “accompanying patients.” He did go to Haiti and Africa and was living and working among those he sought to help. I read Reinhardt as implying that we don’t have the adequate “fellow feeling” (my phrase, not his, of what Farmer had) and that we are too concerned with our own incomes and working conditions to put patients first above our personal concerns. Reinhardt quotes Farmer:
To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end. . . . There’s an element of mystery, of openness, in accompaniment: I’ll go with you and support you on your journey wherever it leads. I’ll keep you company and share your fate for a while. And by “a while,” I don’t mean a little while. Accompaniment is much more often about sticking with a task until it’s deemed completed by the person or people being accompanied, rather than by the accompagnateur.
Reinhardt imagines that the commitment to “accompany” those suffering from the downside of the social determinants of health, “the other,” is similar to a religious commitment. He references Farmer again when he calls it “theological”. He knows this is impossible, but it should be the goal as we attempt to move beyond our focus on self and strive to politically engage in the effort to improve the social determinants of health.
This orientation demands a commitment to the other as the one who sets the goal and charts the path. It requires the one who commits themselves to accompanying to recognize and bracket their own assumptions, desires, and systems of value so as not to overwrite the otherness of the other with oneself. Like the most worthwhile goals, this is ultimately impossible; accompaniment will always demand more of us than we will manage to fulfill. But it is precisely through a persistent distance from the horizon of genuine justice that we can know we are keeping it in sight rather than replacing it with a mirage of our own self-satisfied righteousness.
If your response is, “I can’t do that,” Reinhardt understands as he says, “…this is ultimately impossible; accompaniment will always demand more of us than we will manage to fulfill.” He suggests that just being aware of how hard it is to focus on “the other” and try to accompany them will keep the goal of health equity on our horizon. That is doable by all of us and could lead us to continue to focus on what might be possible for us to do politically and together to improve the social determinants of health where we live and work. He calls for “praxis” or putting theory into action to accompany “ethics.” The idea that if you really care, you should take action is not a new concept.
There is much more that Reinhardt has to say, and I will return again to the challenge that he offers to those of us who claim that we really want to improve the social determinants of health. My goal in this week’s reflection is a little like Don Berwick’s admonition to “think globally and act locally.” I hope that you will strive to do what you can to align the effort to improve the social determinants of health within the work you do. I hope that you will invite or join colleagues to do what you can together to carry the effort outside your workplace to the environment around you. It won’t be easy, but “grassroots” efforts are always necessary and an available place to focus even when efforts in Washington may be fruitless because of our deeply divided, calcified, and diametrically opposed political positions that will undermine efforts to make progress for the next two years.
Winter is When?
I was excited when I looked out the window at my lake last Monday morning. The entire lake was covered in a thin layer of ice. All the lake ice needed was a frosting of snow, and then I would know it was really winter, and we would surely have another “White Christmas.” Alas, it was not to be. It has been raining and in the mid-forties to low-fifties for much of this week. After that tease on Monday, we have had more fog over the lake than ice on the lake.
I had taken the picture below to show the icy surface of the lake, but the picture turns out not to be convincing evidence.
Trust me, the ripples that are usually seen were tamed by the ice.
The header for the post today shows one of the little detours through the woods off the usual route of my walk. When the air over the lake is warmer than the water in the lake we have fog. Through the trees, you can see the fog over the lake. It is a peaceful scene which reminded me that there are some advantages to not having snow. I would never venture off the road if there was snow.
I have been looking at the long-term weather projections. We are warm, above freezing during the day, through most of next week. There is a small chance of snow next Thursday followed by rain on Friday so my guess is that there will be more fog than ice on the lake for the foreseeable future. The TV weatherman says maybe, just maybe, the week before Christmas things might change.
Are we experiencing the impact of global warming? Maybe, but I hope not. I hope that for your holiday cheer more traditional weather patterns will return. Whether you share my hope or not…
Be well,
Gene
