California Dreaming?

A Case Study in the American Malaise.

So just what is wrong with America? Of course, there are those who think nothing is wrong; who over the past 10 years have been the beneficiaries of the greatest redistribution of wealth--to the already wealthy-- that has ever occurred in the history of the Republic. But there are those whose experience has been different and who have faced the reality of an increasingly elusive and withering American Dream.

What does this have to do with healthcare? The answer is: a lot. One of the fundamental determinants of the health of the country’s population is not the number of physicians or even the money spent (US spends more than 17% of GDP, far more than any other country, and gets at best variable and mediocre results), no, the biggest determinant of overall health is distribution of wealth. Where there are gross disparities in income and wealth, there are predictably gross disparities in health outcomes and health status as well.

Sometimes it takes an artist, a bona fide writer (unlike me) to truly shed light on things as they are. I recently received an essay from a friend and Silicon Valley writer, Gary Garvin, who puts it far better than just about anything I’ve read. The link to his full essay, “Gloriously Pointless”, can be found at http:// rggblog.wordpress.com. Particularly poignant to me is his observation about how much money has flowed through Silicon Valley without leaving any enduring legacy of community improvement for people like Mr.Garvin, his family and the students he teaches in the community college system of California. Here’s an excerpt from Mr. Garvin’s essay:

‘One of the factors that has shaped my life and which has gotten progressively worse is the hassle of going from A to B, the stalls, the noise, the urgent, massive crowding. The freeway was rough everywhere, with cracks and patches and asphalt warps, reminders we might be living on borrowed time. Still, the scenery was pleasant once we put the Silicon Valley sprawl behind us, the bare, softly rolling hills, fully green from winter rain, soothing and sensual. Yet the hills would turn dead brown in the coming rainless summer, as they always do, and it was hard not to think of grass fires, the Oakland fire, mud slides, and earthquakes, the faults beneath the smooth veneer of the California landscape.

Traffic, of course, is not a big deal and it is much worse elsewhere. We get used to it and put this irritation aside. It would be madness not to do so. Earthquakes seldom are a big deal either, and most who have lived here long enough don’t pay much attention. We learn to roll with the punches—this is what defines the California character—yet after thirty years I still haven’t settled in, and each time I feel a tremor, something inside me slips a bit.

I wonder what else we have inured ourselves to, with what effects.

I am worn out and dispirited, for personal reasons I won’t bore anyone with. I will, however, look outside. Part of the problem, mine and ours, as with freeways, is the size and complexity of the facilities and institutions that determine the course of our day-to-day lives, the distance, separation, and simplifications—and chaos—these can cause. But I haven’t heard much discussion about issues of scale, and our solutions tend to larger schemes.

An enormous amount of money has poured through Silicon Valley the last decades without beneficial effect on its environment or the quality of its life and culture. Now many of us are scrambling, and if we took the time to leave the freeways, we would find more of us are doing much worse. Yet all these years, prosperous and lean, the state has gone through a series of budget crises, the current one the worst. Services have been cut, the infrastructure left in varying states of disrepair. Public schools have endured perpetual hiring freezes and layoffs, and program cancellations and increases in teacher loads. Like earthquakes, budget shocks have become a permanent part of our economic climate. But that cannot be a problem of size, but of priorities, or of something else we have not looked at and factored in.

I have taught at seven schools, three of them with some reputation, and the experience has not been wholly rewarding. Faculty at all are competitive and contentious, the departments specialized and divided. Not only is there no mechanism in place to give support and recognize basic needs, the language does not exist to express them. The humanities can be less than human, and sometimes inhumane.

I am not alone. Many I know of my age, in teaching and in other professions, here and throughout the country, are in the same shape and they voice similar concerns. Like me, they didn’t see it coming.’

So why doesn’t the money “stick”, or the culture cohere? Is it because taxes and cooperation are for suckers? Is it because the era and legacy of Ronald Reagan so thoroughly legitimized greed and the obsessive pursuit of self-interest that there is simply no thought paid to giving back or belonging to something larger than our own reflections? And the corollary question is: as a result of this spiral of social disintegration, have we totally lost our bearings and connection to any physical place or community? I fear that, ultimately, when this happens it is only one more small step to losing even more fundamental human qualities such as compassion and caring. How often in the past three decades have we heard those who are less fortunate callously dismissed as mere “losers”? Are we becoming a nation of a few haves and many losers?

So ask yourself: Is this the America I’ve always believed in? If not, where do we go from here? I think many of us would agree that the current path is not one we would care to continue on to its logical terminus. Not only our health but our very survival as a civil society depends on changing course. Are we up to it? Do we have the moral strength and political courage? In many ways, a health care system is an indicator of so much more. It is really nothing less than a reflection of how we chose to live and what we hold dear.

The Tall Poppy Syndrome

You can’t spend much time in New Zealand before you hear about the infamous “tall poppy syndrome”. It seems to be part of the psychological fabric of this country and most would agree it has a meaningful influence on the national psyche here. The problem is that people differ, often vociferously, on just whether this a good or bad thing.

What is the tall poppy syndrome? It’s the widespread feeling that individuals who are, quite literally, outstanding, or persons that have distinguished themselves in some way, have somehow violated the social contract to remain part of the group. There is a deep mistrust of success with the implicit suspicion that it is attained through tainted means involving varied degrees of self-promotion, aggressive behavior, manipulating connections, or bending the rules. Unlike the United States with it’s myth of the ‘rugged individual’ and the self-sufficient pioneers, New Zealand has a long history of a significantly more social and egalitarian ethos. In his definitive history of New Zealand, historian Michael King quotes the late 19th century New Zealand politician and later High Commissioner to the British government,William Pember Reeves, who stated in his 19th century history of New Zealand entitled, The Long White Cloud, the following regarding the liberal reforms of the late 19th century that resulted in New Zealand being the first country in the world to grant universal suffrage not only to women but to indigenous people:

‘They were the outcome of a belief that a young democratic country, still almost free from extremes of wealth and poverty, from class hatreds and fears and the barriers these create, supplies an unequaled field for safe and rational experiment in the hope of preventing and shutting out some of the worst social evils and miseries which afflict great nations alike in the old world in the new’.

This in a nutshell summarizes the political and social underpinnings of a centralized governmental system that influences the character of New Zealand society even to this day. Of course, this was the Anglophilic, Pakeha (European) perspective in New Zealand. From the standpoint of the systematically displaced and neglected indigenous population, the Maori, this sort of egalitarianism was simply not a reality in late 19th century New Zealand-- less than 40 years after the Europeans perpetrated systematic treaty violations and widespread land grabs, often by military force.

But ironically, even in traditional Maori culture there have been values that contribute to a more communitarian and cooperative ethic than is found in more competition-based societies. The Maori concept of utu, the practice of achieving balance and reciprocity in social and political affairs, is, oddly enough, in alignment with the more egalitarian aspects of Pakeha culture and governmental institutions. Utu was often translated during the era of Maori/Pakeha conflict as “revenge”. But, to quote Michael King again:

‘it more properly means reciprocity or balanced exchange. Utu determined that relations among individuals, and between families, communities and tribes were governed by mutual obligation and an implicit keeping of social accounts: a favor bestowed which increased the mana (prestige) of the donor, required eventual favor in return from the recipient; and an insult by one, real or imagined, also activated an obligation to respond in kind’

As warfare between the Pahkea and Maori abated and violent intertribal conflicts diminished, the concept of utu became ritualized with cooperative and competitive endeavors between Maori communities throughout the country becoming the norm.

As can be seen, there are powerful traditions in New Zealand among both the Europeans and Maori that oppose the emergence of “tall poppies”. Whether this is a good or bad thing depends on who you’re talking to. There are those who argue passionately that New Zealand has low standards for excellence and simply cannot compete economically and academically with more individualistic, competetive and aggressive values found in places like the United States. For others, the vast wealth disparities and lack of social cohesion-- and even dysfunction-- that frequently afflicts community and political life in the US (like with health care!) are seen as examples of why the tall poppies are undesirable.

Of course, both sides are right. As in all things, the trick is finding a critical balance between individuality and community cohesion. In the arena of healthcare, the system in New Zealand certainly is more coperative and socially based than that of the US and has, I believe, much to teach us. On the other hand, the innovation and pockets of excellence that can be found in the US offer models for change and improvement that could benefit the delivery of healthcare here.

To me it really comes down to just what sort of tall poppies are cultivated or tolerated. If it has to do with granting someone the intellectual or artistic freedom to innovate and excel, I’m all for it. But if, as is so often the case in the US, the tall poppies are merely self-important, arrogant egomaniacs from, for example, the corporate CEO caste or the entertainment world, who actually believe that their day-to-day activities are worth millions of dollars per month to society, then I truly hope New Zealanders continue to prune those plants in the community garden quite carefully.

Every individual is unique and has talents and dreams that should be allowed to flourish, but we must also understand that we are fundamentally social beings and that we are deeply rooted in the soil of social cooperation. Indeed, without that cooperation, we would not have achieved the things we have, nor in all probability, would we be here at all.

You’re Dead Wrong, Jay Inslee (D -WA, 1st)

Last summer as the infamous town hall meetings played out across the country, I experienced my initiation into the world of health care reform and public politics. In the gymnasium of the North Kitsap High School in Poulsbo, Washington, I was one of

thousands of concerned citizens who turned out to hear our congressman, Jay Inslee, Democrat, 1st Congressional District, Washington referee a public meeting on health care reform. From the outset it was clear that there was a well orchestrated contingent that was bent on disrupting the proceedings and propagating well scripted lies and disinformation about the issues. As my name was called to comment half-way through the proceedings, I experienced my political debut and transcended my normal reluctance to address public audiences. After I got the microphone and in the brief time allotted to me, I tried to refute as much of the disinformation as possible and to frame the case for meaningful single payer reform. It was clear, however, that even the “liberal” Democrat Congressman was not really invested in medically meaningful reform.

I must commend Mr. Inslee on the way he handled the fractious and potentially disruptive crowd. However, I was disappointed but not entirely surprised when he concluded his summation by reaffirming his belief that litigation is a means by which the quality and the integrity of healthcare can be assured. The right to sue, according to Mr. Inslee, is to be preserved to achieve this goal.

This philosophically blinkered and transparently self-interested perspective (he is a lawyer, after all) is among the greatest reasons that the US health care system is so completely dysfunctional. (Aside of course, from the predatory practices of the health insurance industry--but that’s a topic for another time). Alternatives such as universal health insurance which obviates the need to sue for expenses, or socially regulated, truly mutual, no-fault, non-profit insurance schemes were just not on his radar.

Of course, to listen to the academic discourse on health care costs might lead one to conclude that he is right. Frequently stated in the press, in think tank statements, and amongst the policy wonks is the notion that the cost of litigation contributes very little if anything to the runaway costs of health care in the United States. Author Tom Baker, a lawyer, in his book, The Medical Malpractice Myth, published by the University of Chicago (no less) states blithely that “the real problem was too much medical malpractice, not too much litigation”. He dismisses the impact of manifest and hidden costs of malpractice litigation as an “urban myth”. Aside from the obvious failure to transcend professional bias, Mr. Baker is part of a wider academic failure to comprehend the very real day-to-day impact of what has frequently become nothing less than a system based on adversarial patient care.

He is not alone. Academicians such as Greg Bloch from Yale, are quoted as maintaining that at most 2% to 3% of the multi-trillion dollar health-care expenditures in the US are attributable to litigation and defensive medicine. That translates to “only” $55 B per year. How much care would that provide in underserved areas of the US? Such analysts even tout their dual law and medicine degrees, but it is a safe bet that such people have never once had to deal with the ethical and financial dilemmas that are a daily routine in real-world medical practice in the US.

The reality is that the toxic influence of adversarial patient relationships and the spiraling mutual distrust that characterizes many patient-physician encounters in the US has utterly poisoned the formerly advocacy-based and sacred physician-patient relationship. Any lawyer or academic apologist for this adversarial, litigation-based system that is rampant in the US has never walked a centimeter in a clinician’s shoes. If they had, they would understand that the implicit threat and the mutual wariness that characterizes most clinical encounters in the US are destructive to the very foundation of any sort of rational, humanistic, population-based, not to mention effective, healthcare delivery.

This also results in the paralysis of clinical judgment, the undermining of collaborative treatment and results, at its very heart, in the destruction of the very power to heal. And it is yet another example of the cynical reduction of health care to a commodity that can be manipulated for personal financial gain as a part of the self-perpetuating and ultimately self-defeating cycle of self interest that is slowly destroying American healthcare. And this is not just a 2% or 3% proposition.

Of course, if you ask a lawyer like Jay Inslee, they see themselves as a last bastion of hope in the defense of hapless consumers who are subjected to the routine callousness and arrogance of the medical profession. Life is just one continuous John Grisham novel where self sacrificing lawyers are the only ones who truly care. In fact, the health care policy literature is rife with statements by legal academicians to the effect that litigation is the last best hope for quality assurance and high standards in healthcare. It simply does not occur to them that there are other far less self-interested, costly, and destructive means to the same ends. How on earth can a 30% contingency fee be a tool of health care quality assurance or reform? In fact, a truly dispassionate observer might rationally conclude that the role of litigation and its manifestly adverse impact on the very foundations of health care are not only misguided but ultimately constitute nothing less than a parasitic extortion racket with no concern whatsoever for improving the health or wellbeing of the nation’s citizens.

If there are any lawyers reading this blog who made it this far, I make no apologies, because the effect of this perverse worldview is enormous on clinicians. Perhaps there is fertile ground for researchers less encumbered by conflict of interest or legal indoctrination to explore just to what extent quantitatively this perverse arrangement actually has on healthcare delivery and cost. However, as a physician who in almost 30 years of practice has never been sued, (probably a combination of competence, common sense and luck) but who has witnessed conscientious, compassionate, humane colleagues utterly destroyed by capricious law suits served up on a whim by self-interested lawyers, I can tell you again that it’s a far more more than 2% to 3% impact. Qualitatively, the day-to-day impact on physicins is enormous. And that’s not an “urban myth”.....

I have no personal animosity towards Jay Inslee. In fact, during the brief conversations I’ve had with him, I like the guy. However, the legal profession and the lawyers who become politicians in disproportionate numbers have imposed an antagonistic worldview on our society that simply doesn’t mesh with our better instincts to cooperate and to care for one another. I am convinced this is one of the many reasons that the healthcare “system” in the USA is so irretrievably broken and so impervious to meaningful reform.

Perhaps we need more teachers and plumbers and farmers and poets in Congress. (As well as the sweeping campaign finance reform needed to bring this about.) Perhaps we need to work conscientiously to recapture the communication skills and trust and caring that are central to effective health care delivery. But clearly the present way is not satisfying or satisfactory for doctors or for patients. There will probably always be doctors who are arrogant, incompetent or uncaring. And there will probably always be patients who simply cannot establish a relationship based on trust. But for us to build our entire health system on the cynical premise that is the basis for the misguided adversarial approach we are now taking, is a prescription for therapeutic failure and financial ruin.

Local Politics in Paradise

The late great Tip O’Neill, the former speaker of the US House of Representatives from the US state of Massachusetts once famously observed that "all politics is local". Confirmation of that pearl of wisdom was provided once again last week during my locum stint in the small town of Takaka, which is idyllically situated on Golden Bay in the northwest corner of the South Island of New Zealand. Nestled between Able Tasman National Park and Kahurangi National Park (home of the famous Heaphy Track) and isolated from the nearest city of Nelson by a long tortuously twisting two-lane road reputed to make for the worst driving New Zealand, Takaka has developed a superb and somewhat unique model for health care delivery to its community. The Golden Bay way of doing things has also seen the winds of change that have affected numerous practices and communities throughout New Zealand. Specifically, with the establishment of district health boards (DHBs) and primary health organizations (PHOs)discussed in one of my previous posts, there has been a trend towards standardization, centralization, and in the eyes of not a few, loss of local and professional control. To complicate things further, these two entities, the DHBs and the PHOs are thought by some to be engaged in a power struggle to define their roles and dominance, while the oversight boards of both tend to consist of political appointees, who are often felt not to be entirely dedicated to transparency or democratically responsive or accountable to those their decisions most immediately affect.

One week before I arrived in Takaka, a tentative agreement was reached between various stakeholders in the region, community, and the physicians that will change the delivery of care in this small somewhat isolated place. Specifically, the doctors of the Golden Bay Medical Centre (GBMC ) became employees of Nelson Bays Primary Health, the local PHO. But there was also dissent in the practice and ongoing concerns about professional control, community input, and transparency of management have continued to be a source of controversy and concern.

At issue is the attempt to consolidate the freestanding medical practice, ambulance services, local senior center, and small community-based chronic care hospital. A decision has been reached to move ahead with construction of an integrated health facility at the site of the old hospital 2 km out of town that would encompass all of the services. Unfortunately, this will involve relocating the senior rest home and moving the medical practice from its present downtown site. The primary driver of the choice of location is that it represents the least expensive real estate option for the DHB.

These decisions were reached by a group called the Interim Management Group (IMG)which is made up of representatives from the Nelson Marlborough District Health Board, the trust in charge of the rest home, the GBMC community trust and professional members of the Golden Bay Medical Center. In seven days there will be a community meeting in Takaka presenting the final proposals to the community. There is also another community meeting, organized by a group of dissident citizens, scheduled for April 20. High on the list of concerns is loss of community control and transparency of the process.

In response to those in the US who think that a single-payer plan such as New Zealand’s represents monolithic socialism I would only point to the community engagement so evident in Takaka. What I saw there goes to the very heart of participatory democracy. There is a real struggle afoot to try to reconcile uniquely tailored local solutions with the greater integration, standardization and economies of scale that large organizations can offer.

In a perfect world every community would be able to strike a delicate balance between these countervailing forces and come to a consensus about the best way to proceed. Despite some of the heated opinions and passionate arguments I heard from various sides of the issue, I’m actually quite impressed that the commitment of the community will translate into further expansion and enhancement of the high-quality institutions that already exist.

The integration project’s IMG in their public summary that appeared in the April 16, 2010 Golden Bay Weekly, states that they are happy that the proposal meets the future health “needs’ of the Bay. They also believe that it meets the “wants’ as well. Or as three of the physicians from the GBMC said in their public announcement of their change in employer to the Nelson Bays Primary Health (PHO), “We anticipate that this will be a challenging journey but feel it’s an excellent opportunity to further the provision of health care in our community into the future”.

After the dust has settled I’m confident that Golden Bay will continue to build on its tradition of excellence in healthcare. I hope the community can also look back with pride on its active participation in the process and on the degree to which it demonstrates that, quite simply, they care for one another. Tip O’Neill would be proud of this place.

Stress and Health

Twenty years ago in Japan, cardiologists first described a unique form of heart failure called Takotsubo cardiomyopathy. Cardiomyopathy is a weakening of heart muscle and can be caused by a number of pathological processes including viral infections, diabetes, and most commonly, coronary artery disease. But in the case of Takotsubo cardiomyopathy, the only causal factor that could be consistently found was extreme emotional stress such as the loss of a spouse or loved one. As a result, the base, or apex, of the heart balloons out and causes pain and reduced pumping capacity. And as a result of it's only apparent cause, this cardiomyopathy has also been referred to as "the broken heart syndrome". It has been estimated that up to 1 to 2% of admissions to US coronary care units can be attributed to this pathologically enigmatic disease. http://www.mayoclinic.com/health/broken-heart-syndrome/DS01135

But how can stress alone cause acute cardiac decompensation? It appears that there is a substantial decrease in microvascular circulation as well as an associated increase inflammation-- both of which have been associated with such problems in other cardiomyopathies. In my own clinical practice I've seen patients with no risk factors whatsoever develop sudden heart attacks when informed of catastrophic loss. As I tell patients, we are not simply biomechanical entities. Our emotions and our responses to the environment around us have an enormous impact not only on how we feel, but also how we respond physiologically or pathophysiologically to external stressors.

If acute emotional stress can precipitate a cardiomyopathy, what impact can long-standing stress have on overall health of individuals? Or more specifically, in the context of the stressful unpredictability of healthcare in the United States, what impact might this have on the overall health of our population?

These sorts of questions have been on my mind recently as it has become apparent to me that not only are the New Zealand patients I am seeing less stressed about their healthcare, I too, am feeling less stressed in this place. Maybe it all has to do with a less adversarial and more cooperative society, or maybe it's simply due to a far lower population density than I'm used to, but I have the distinct impression that overall levels of stress here are lower. When you think about it, how could that not be? Patients here don't have to worry on a week-to-week month-to-month basis about their employment status and its impact on their ability to provide healthcare for their families or themselves. Nor do they have to worry about the impact of healthcare on a proposed job change, geographical move, or, for that matter, an entrepreneurial or creative endeavor. Ironically, a comprehensive socially-based health plan such as that found here in New Zealand affords its citizens far greater social mobility than that found in the United States. There is no "job lock" due to pre-existing conditions, no impact of health insurance on career choices. So much for Tea Baggers' concerns about "freedom". As with so many other things, they've got it backwards.

When I think about stress and its impact on the health of specific populations, I can't help but reflect on the seven years I spent in Beaufort County South Carolina caring for a significantly African-American population. Over and above the contributions of diabetes,obesity, and smoking, I saw a disproportionate number of people who had remarkably high blood pressure that was often treatment resistant, despite progress in treating the other associated problems. At the time, an occasional patient would tell me that it was all due to stress, to which I often gave less credence than the presumed physiological causes. But now I'm less sure that those patients weren't right. Generations of poverty, lack of access to healthcare, and yes, racial oppression may well have had a far greater contributing role than I was willing to admit or address.

I now wonder whether the same can't be said for the entire USA. Certainly we spend more money per capita on healthcare than any other country on earth, but in spite of that we have significantly worse outcomes. This can be broken down ethnically, geographically, and socioeconomically but I still wonder whether the stress of life in a country where many people are, to use Barbara Ehrenreich's term, "nickeled and dimed", (or worse...) doesn't play a far greater role than is appreciated by the purely biomechanical research paradigm most often utilized to investigate such medical problems.

Just maybe, if we were to embrace a more comprehensive, universal, humane health system such an overarching adverse risk factor for collective bad health could well be reduced or eliminated. Studies clearly show that one of the greatest predictors of the health status of a population is distribution of wealth. Perhaps the corrollary, collective stress, is equally important.

As for me personally, I will be monitoring my borderline elevated blood pressure to see if my personal perception of reduced stress translates into something physiologically demonstrable. I think it might....I'll keep you posted.