25 January 2019
Dear Interested Readers,
Who Is Responsible?
A few weeks ago, for the first post of the year, I returned to writing about the intersection of poverty and healthcare. One motivation was the realization that this year was the beginning of the 2020 presidential campaign, and I am anticipating that each candidate will be presenting his or her points of view about healthcare access, improved education, perhaps free college, full employment, better housing, the unfair burdens shouldered by the middle class, and how to fix all that seems broken. I have a great sympathy for this agenda, but in the election cycle that we just completed I was surprised by the lack of any in depth discussion about poverty, and I do not believe I heard healthcare discussed beyond its cost, the persistent numbers of people without access, and the rapidly rising cost of drugs. I am sure that somewhere some politician did talk about poverty, but I did not hear the speech.
I am nervous that in this next election we will just focus on the debate over whether we can solve our problems with a shift to Medicare For All or whether we should revamp the ACA. If that is all that is discussed and debated we will make precious little progress toward having a healthier nation. Ensuring access to quality care with no concern about expense as a barrier to getting care is an important objective, but the data is clear that poverty and the misery we perpetuate by not looking at the larger picture of the social determinants of health should be as much our concern as universal access.
One neat thing about living in New Hampshire half the way from Concord to Lebanon/Hanover is that all the “wannabe” presidential candidates pass through my little town. We have two convenient exits off of I 89 and they see New London as a picturesque stop populated by relatively affluent potential voters who also make campaign contributions. I have already been in the same room as Senator Elizabeth Warren, former Congressman John Delaney (click to read column by George Will), and Senator Jeff Merkley. Our “First in the Nation” primary is just one year and two weeks away. Between now and then I hope to be in many more small group discussions with candidates. It will be fun to see which one of many will win the prize of the nomination for a chance at the world’s most difficult job. The current expectation is that there will be over twenty Democratic “wannabes” suggesting that they are the one that has “The Answers.” I am not sure yet if any of them really understand the questions that must be answered to remove the barriers to the Triple Aim.
I think that all the Democrats and some Republican politicians would agree that the Triple Aim is a very good objective. They would not object to the goal of better healthcare for individuals and healthier communities at a sustainable cost. The barriers to the Triple Aim arise from the confusion about the difference between healthcare and health, the disagreement about the methods to use to achieve the goal, and whose responsibility it is to move us toward the goal. I should also add that it is equally unclear as to whom we should blame or chide for our current status.
I heard Jeb Bush speak this week at an engagement in Boston. He is an affable fellow who enjoys talking about his parents, his famous brother, and the experience of being ridiculed by a narcissistic bully. It was an entertaining evening. We were on the same page while he was talking about goals for the country. He wants to improve education. He wants everyone to rise out of poverty and be healthy. We both see the benefit of innovation. We agree that artificial intelligence is both a potential benefit, and will create huge challenges. We both want to see a fair and workable immigration policy that will bring new talent to this country and allow people who are threatened by violence to come here for asylum. Also, we are both appalled by the deep divides that exist in our government, and the frightening way our current president has departed from the norms of good government.
We go separate ways when he says that Betsy DeVos has us on the right path in education, and that despite the president’s objectionable personality and methods, he has made good appointments to the Supreme Court, and that his tax policy is the right call. After listening to Mr. Bush talk about the ACA as a mistake it is clear to me that if the president were to go away tomorrow there would still be deep differences in points of view to negotiate within our political system. Jeb and I would agree that all of us need to get better at compromise if we are ever to be able to move forward on many of the issues that constitute the social barriers to better health.
I have been concerned about the social determinants of health for a long time, and I have also realized for a long time that in many ways it is a discussion of the appropriate social safety net. It is also clear that any individual’s opinion about the social safety net is a function of how they see issues of personal responsibility playing out in the origins of poverty and illness. The issues are even more complicated for healthcare professionals because we have our own varying points of view about the personal responsibility that our patients have for their own health and what our professional responsibility is to them.
When I was in a leadership position I would often hear a clinician complain that their patient was “non compliant.” When I heard their concern I often wondered whether or not they were really saying, “I do not have the professional skill or perhaps the organizational support to help this person.” It is complicated. Patients surely have a “responsibility” for their own health, but what resources and help do they need to fulfill that responsibility? To show how critical and complicated the question is one need only to remember that Paul Ryan and others were very straightforward about the need to cut Medicare and Medicaid spending to pay for the tax cuts given to corporations and the wealthy.
Many healthcare professionals share my concern about the social disparities that impact the health of their patients, but are not quite sure just what their own responsibility is. I do not hear people pushing back by saying that poverty does not impact health, but I do sense that within healthcare, as well as within our society as a whole, there is divided thought about whether or not “health” is an individual or a collective responsibility.
The issue of whether the government has a responsibility to provide a social safety net or not has been a huge debate in our society for most of the last hundred years. Federal and state programs financed from taxes are generally lumped together as “entitlements.” Our personal attitudes about entitlements are a major factor in our political opinions, since entitlements are translated into public policy and attitudes about public policy translate into political opinions that then are expressed as votes for a candidate who pledges to either increase or decrease programs. Entitlement programs are a huge driver of the need for taxes and tax questions drive political opinions.
Poverty is a complex subject that is hard to discuss. It is even harder to write about poverty without sounding paternalistic or moralistic. There are few people who can keep the discussion at a level that is not distorted by some bias. I was delighted, but not surprised, to discover that Don Berwick had constructed a very positive and informative discussion of the social determinants of health in his most recent speech at the IHI annual meeting, and I tried to pass some of his wisdom on to you last week.
Don suggested to the audience that everyone should buy and read Sir Michael Marmot’s book, The Health Gap:The Challenge of an Unequal World. I trust Don, and although he presented the suggestion that everyone should buy the book as a joke, I decided to follow his suggestion. My copy arrived on Tuesday, and now I can say Don was right. Chapter Two: ”Whose Responsibility” directly addresses one of the biggest issues, personal responsibility versus societal responsibility, that makes the discussion of the social determinants of health and all entitlements very difficult to manage in our political system.
Marmot begins the chapter, “Whose Responsibility,” with two lists. The first list is from England’s Chief Medical Officer. Most of us in practice have repeated the same sort of list to our patients. We have low expectations when we make our suggestions, but it is the right thing to do.
- Don’t smoke. If you can, stop. If you can’t, cut down.
- Follow a balanced diet with plenty of fruit and vegetables.
- Keep physically active.
- Manage stress by, for example, talking things through and making time to relax.
- If you drink alcohol, do so in moderation.
- Cover up in the sun, and protect children from sunburn.
- Practice safer sex.
- Take up cancer-screening opportunities.
- Be safe on the roads: follow the Highway Code.
- Learn the First Aid ABC: airways, breathing, circulation.
Marmot continues by offering another list that was created by David Gordon and colleagues at the University of Bristol.
- Don’t be poor. If you can, stop. If you can’t, try not to be poor for long.
- Don’t live in a deprived area. If you do, move.
- Don’t be disabled or have a disabled child.
- Don’t work in a stressful. Low paid manual job.
- Don’t live in damp, low quality housing or be homeless.
- Be able to afford to pay for social activities and annual holidays.
- Don’t be a lone parent.
- Claim all benefits to which you are entitled.
- Be able to afford to own a car.
- Use education to improve your socio-economic position.
There is no question that the first list is one where issues of choice, agency, and responsibility may be appropriate. The second list is a compilation of factors that could contribute to health and well being, but whose responsibility are they? What is the interaction between the two lists?
Marmot argues with economists who say that we make “rational” choices based on valuations of current versus future satisfaction. Using that theory one can theoretically explain why someone chooses to overeat, drink too much, or abuse alcohol. They are choosing the moment over the future. Marmot rejects that formulation even though it is full of “personal responsibility.” Advocates of absolute personal responsibility can even apply their theory to the second list. They can say that unemployment is primarily a lifestyle choice, and that poverty is explained by laziness as a personal choice. That is what President Reagan and some of his current worshipers would imply when they talk about “welfare queens.” Marmot is not buying it. In reference to the first ten he would say that individual behavior choices are influenced by where people find themselves. People’s ability to take personal responsibility is shaped by their circumstances. In reference to the second list he says that people cannot take responsibility if they cannot control what happens to them.
Smoking, alcohol, obesity are causes of disease and contribute to the the “social gradient in ill-health.” Marmot’s quest is for the “cause of cause.” He says,
“Trying to influence behaviour by addressing the ‘causes of the causes’ evokes strong reactions. On one side of the argument, public health advocates demonstrate that big business has too much influence on health policy—in relation to tobacco, alcohol, and food, for example. The other side alleges that any government interference is an intolerable erosion of liberty, letting business have a say is not lobbying against government policy, it is simply democracy.”
Well, it is reassuring that the same left/right disputes occur in the UK even though they have universal coverage.
Marmot gives us a robust argument that environment has a huge impact on choices. He is giving us an explanation for why health varies by zip code. He stresses the importance of “empowerment.”
“I argue that central to improving people’s health and well being is empowerment of individuals and communities…But when we see regular patterns of social behavior it suggests that there are broader, social, causes…Knowledge is but one step to empowerment…Poverty and inequality are deeply disempowering. People with little control over their lives do not feel able to make healthy choices.”
He finishes by advocating that to improve health we must:
“…create the conditions for people to have the freedom to lead lives they have reason to value.”
It will be a lot of work. I am hoping that someday this year a candidate will pull off Interstate 89 at Exit 12 and paint the picture of how we might get down to the work of improving the health of everyone in this nation. I am living in that expectation.
Surviving Moments of Great Tension and Big Swings In Temp
I came close to having a cardiac arrest several times last Sunday evening while watching the game between the Patriots and the Chiefs. Being a fan of a team that is as successful as the Patriots is stressful, even between games. I was stunned to see a map of the country that showed that Patriots fans were in short supply outside of New England, except for Michigan where the “World’s Greatest” played his college football.
I can understand why fans in Georgia and Seattle dislike my team, but their teams really beat themselves. In the end it is “unforced errors” that cause the greatest damage. It was unforced errors that sank the hopes of the Seahawks and the Falcons. Why do fans in New York hate the Patriots so much? “Spygate” was a long time ago, 2007, and the Giants have beat Brady’s bunch in the Super Bowl twice since then in games the Giants did not deserve to win. I know Spygate was an offense against the Jets, but losing to the other New York team should provide some sort satisfaction to those who trudge through difficult lives in The City That Never Sleeps.
Why should people in Denver be such Belichick bashers? Belichick gave them at least one Super Bowl. He blew the last game of the season in Miami in 2015 which gave the Broncos home field advantage for the AFC Championship game against the Patriots. That allowed them to win a close AFC championship game in Denver that set them up to win the Super Bowl against the Carolina Panthers. I just don’t get it. Eagles fans should like us after they beat us last year with a trick play. Why don’t people in the Bay Area care for us? What did we ever do to them? We were helpful to their cause. We gave them Garoppolo who when he gets well could be their savior for the next ten years. I just don’t get why they hate us.
After surviving the dump of snow that preceded the Patriots game our temps fell to minus 12 and on Monday the high temp was minus 2. That was an educational experience for me. My car tells me what the air pressure in the tires is. The usual pressure is 32. At below zero temps my “cold tire pressure” was 27! I think that exonerates Brady from all the innuendo associated with “Deflategate.” It’s obvious. The balls were inflated where it was warm, and the air pressure went down in the cold. I believe in science!
Speaking of science, I also believe in climate change. The temperature changed a lot this week. There was heavy snow on Sunday followed by a low of minus 12 on Monday. By Wednesday it was in the forties and yesterday the high was almost 50 in torrential rain. That’s a 60 degree swing! We have had a weird winter, but as today’s header proves, there have been some very beautiful days. The scene was captured by my neighbor with his drone, but it could have been snapped from the top of the favorite sledding hill on the golf course near the “turnaround” on my usual walk. I did not try to walk outside in subzero temps. Below ten degrees I head to the gym at our little college, Colby Sawyer. Whether it’s indoors or outdoors I hope that you will get some exercise this weekend. Remember the list. It is a choice for health. Tom Brady is the poster boy for the benefits of a sensible diet and a good exercise program.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
