Damaged Care

*A transcript of this talk can be found here, or the mp3 can be purchased at this link.

Stephen Bezruchka opens his talk with an analogy about a town on the coast, with great hot springs that attract many tourists. The road leading to the town affords a breathtaking view, but comes perilously close to the edge of some cliffs before turning left into town … occasionally cars plummet over the edge. Enough cars begin to fall over the edge that the town leaders get together and hire experts and consultants to figure out what can be done. After studies and analysis, the answer is found, and the town leaders announce they will build a state-of-the-art trauma center at the bottom of the cliff.

I was having dinner with my parents tonight when the topic of aspirin as treatment for heart attacks came up. My mom hadn’t heard that aspirin can lessen heart attack damage, so I quickly ran through the necessary info (no aspirin for those on blood thinners or with allergies, only one adult aspirin (325mg), ensure the aspirin is chewed). I then mentioned Bezruchka’s analogy. As an emergency physician, he’s in a position to be keenly aware of the backwardness of our societal approach to medicine. As an EMS instructor, I often teach about aspirin’s potential use in reducing heart attack damage, and so I’m sympathetic to Bezruchka’s point: as a society we expend too little effort on prevention.

He points out that the US comprises 5% of the world population, yet 50% of its healthcare spending. In 2005 we spent 15.6% of GNP on this healthcare (about $7k per person, 1.94 trillion dollars). The increase in healthcare costs from 2000 to 2005 represent 24% of our economic growth during that period. Our societal position of health relative to other countries has declined, is declining. He correctly points out that we’re “as healthy as Cuba, the country we’ve been strangling for 45 years,” although I wish more attention was paid to Cuba’s health indicators in his talk.

Cuba has some of the most effective, preventative, and equitable healthcare in the world, and although I believe the societal attitudes between the US and Cuba differ too much for Cuba’s healthcare to serve as a direct model for the US, I think it’s worth a closer look anyway. This is a write-up of Bezruchka’s talk, though, not my monologue on Cuba, so I’ll save that for a different time. If you want to know more about Cuban healthcare, this is a great film.

So Bezruchka correctly points out that our health improvements are less effective than any other rich countries, yet more costly than any others. We rank at the bottom for infant mortality, maternal mortality, quality of life, happiness, life expectancy, and so forth, when compared to other rich countries, and even to some poor ones. Our teen birth rate is twice that of the next closest rich country. We have more homicide deaths. This is what one sixth of our GNP amounts to. Our “healthcare doesn’t seem to be buying us health,” Bezruchka elucidates.

“Once everyone’s basic needs of food, water, shelter, and security are attended to, it is the way a society cares for — and shares with — its members, that’s what impacts its health.” For me, this quote nails it. Health inequalities are one of the least talked about aspects of quality of life and healthcare in the United States. Yes, we talk about the number of uninsured, but that’s about as far as we go when addressing inequality. There is little talk of the care (or lack thereof) or outcomes that someone can expect if they are white instead of brown, upper middle class instead of poor, and so on. He quotes Richard Wilkinson, “Inequality kills. We should then liken the injustice of health inequalities to that of a government that executed a significant portion of its population without cause.” I’ll review a Tim Wise talk in a few days where he cites a public health study that found one million black Americans die every year simply because they are black — their white counterparts, with different social and economic determinants, don’t die.

Bezruchka introduces the wonderful term, profitcare, to refer to HMOs and other institutions that are profiting fabulously while small businesses and individuals find themselves struggling to maintain solvency due to their healthcare dealings. He notes we have the smallest middle class of all rich countries. In the 1970s the average worker spent about 50% of his income on fixed costs, and 50% remained for discretionary income, versus this century, where it’s closer to 80/20.

Dr. Bezruchka recounts the experience of becoming a doctor and realizing that some patients are actually being harmed by their care — that is, they would have been better off to have received no care at all. The first systematic study of medical harm, done at Harvard and published in the NEJM in 1991, found adverse events from medical care amounted to 4% of admissions. Of those, over 13% meant a death that would likely not have occurred had care simply been withheld. This could mean, at that time, about 100,000 deaths occurring in hospitals across the US that shouldn’t occur. Two further statewide studies (UT, CO) validated these conclusions. Half of the deaths were due to negligence, mistakes, and so on, with the other half being due “the nature of the medical care beast; namely, people were harmed by medical care done right.” Emphasis mine.

Continuing with his citations, the doctor mentions the Federal Body of the Institute of Medicine and it’s 2000 report, “To err is human.” The report states that 44,000 to 98,000 people die yearly in hospitals in the United States from medical errors, but as Bezruchka points out the report doesn’t address the medical care ‘done right’ that seems to kill an equal amount.

“Are you willing to consider that medical care can be a leading killer? How can we find out if this is true or not?”

He cites Barbara Starfield, a medical doctor and researcher at Johns Hopkins who wrote (JAMA July 26, 2000 — Vol 284, No.4),

“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, have been increasing. A conservative report of the number of deaths in the United States that result from adverse effects from medical treatment is 10%. In other words, an estimated 275,000 of the total 2.5 million deaths a year that are annually attributed to specific diseases are really the harm from interventions.”

From here Bezruchka compares this number of dead to the September 11th attacks (one would need to occur every four days to keep pace), and introduces my favorite phrase: structural violence. He gives personal examples of poor outcomes that needn’t be; examples not from his medical practice, but just people he knows. His sister-in-law bleeding to death on an operating table from a cancer surgery. “Had she not had the surgery, she would likely still be here today.” His next door neighbor having liver surgery in a top-ten hospital and also dying in a similar situation.

A boy in the 1950s who received radiation to his head for his acne, later to develop cancer deep in the tissues where his acne has once been. “We now know that treating acne with radiation is not good for people, but back in the 1950s that was how localized acne was treated.” He develops this concept of smart-treatment-found-to-be-dangerous further by mentioning HRT and Vioxx.

He names several studies that find that death rates drop when doctors go on strike. “Unless it is really clear that doing something will help, and there isn’t much chance of doing harm [don’t do anything].” He argues that primary care is the route to better health, rather than specialist care. This is where I think aspects of the Cuban model could be emulated successfully in the US; Cuba has limited resources and equipment, and relies on preventative care and a high doctor-to-patient ratio for the continued health of its people.

Bezruchka argues that servicing the desires of large corporations and neglecting the poor, as well as allowing the poor to blame themselves for their low incomes serves only to further our problems of morbidity and mortality. “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, while at the same time creating more and more poverty, especially relative poverty, measured as the height of the cliff between the rich and the poor.” Dr. Bezruchka nails it here, especially with his reference to gradients of inequality.

I made a lot of notes while working in Nigeria — notes about ways in which Nigeria, or some within it, were better off than Ghana, but also ways in which many people were worse off than their Ghanaian counterparts. In almost all cases, corruption and inequality are that the root of this impoverishment. It was the gradients of inequality that I saw in Nigeria that led to the poorer prospects for the Nigerians we saw, as compared to the many Ghanaians I’d seen every day, people who are not rich, but at the same time aren’t separated from the more elite in Ghana by such distance. The more egalitarian nature of Ghanaian society leads to a better life for the average Ghanaian, however small that improvement may actually be.

Bezruchka points out we have the highest poverty rate of any rich country.

“We already spend more money — more government money — at the federal, state, and local level on healthcare per capita than any other country spends in total on healthcare services per capita, yet we have more than 45 million people without medical insurance coverage. So without spending a penny more for healthcare, just by restructuring the system we could provide medical care for all. But we’d have to change our profitcare approach.”

“We should be close to the gold medal in the health Olympics, instead of coming in 28th place today.”

Dr. Bezruchka’s argument isn’t that we shouldn’t treat disease, I am quite sure that he thinks we should. He argues, however, that we expend too much energy focused on disease, and too little on health. Too much energy on preventative screenings and procedures that do not produce a net benefit. Too little effort on addressing the underlying determinants (both economic and social) of health.

The determinants of health can be a tricky concept … although for me the idea is somewhat intuitive, a professor-and-sometimes-collaborator of mine has assured me that she has to spend weeks working to teach each new class of students to the point that these determinants can be understood. Bearing this in mind I don’t presume to think I can do them much justice in a few sentences, and indeed Dr. Bezruchka (who is quite eloquent) uses an entire hour of his talk to barely scratch the surface. The idea in addressing the determinants of health is to look at what actually makes people sick, rather than address solely the sickness itself. Again, we can expand our focus beyond simply disease and look at the abilities of people to be economically and socially productive, at the whole picture that is “health.”

“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.'”

“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!”