Medical Homelessness

It has now been 6 months since I returned to the US following my 3 month roving locum in New Zealand. I knew I would need time to process the experience and to reintegrate into my former personal and medical life here, but I was surprised that I was unable to pull some thoughts together for the blog until recently. I’m normally a verbal sort of guy, and this was my first encounter with the dreaded “writer’s block”. I’m sure it was the result of re-entry into the surreal world of US healthcare.

In many ways, the most jarring part of this re-entry occurred in the first few months as I resumed clinical practice here in the US. The differences between Kiwis and Americans in patient attitudes, trust, demands, sense of personal responsibility and perhaps most telling, willingness to take ownership not only of their own health but also for participation in providing health care for fellow citizens all presented a stark contrast.

And as for the US health care system itself, I found it astonishing that the proponents of President Obama’s recently passed but inadequate and compromised “Patient Protection and Affordable Care Act” (PPACA), had more or less declared victory and changed the subject. There had been an enormous amount of activity in the run-up to reform but to me it all seemed to be tantamount once again to rearranging the deck chairs on the Titanic. The fatal design flaws and hubris at the helm remain in place--even as the recession continues to grip the country, unemployment benefits are held hostage to making tax breaks for the wealthy permanent and even the “insured” are being squeezed by higher and higher shares of premiums that provide less and less. And nowhere is there any talk of cost containment, let alone universal access....

In lieu of meaningful systemic change, micro-reforms are being touted as the next new thing. Nothing is literally or figuratively more descriptive of the shortcomings of these “innovations” than the so-called patient centered medical home.

Several months ago, writing in the Journal Health Affairs, a group of colleagues at Group Health Cooperative in Seattle shared their experiences with developing and implementing a new primary health care model termed the “Medical Home” . The concept of the medical home is to improve the primary care delivery experience for both patients and care providers in a number of ways, including:

• improved access,
• more timely and efficient communications,
• application of coordinated--often electronic--record keeping,
• quality improvement through implementation and tracking of care standards,
• employment of active case management.

Many of these “new” ideas incorporate functions of successful past primary care practice models that unfortunately have become increasingly rare or that were seldom carried out in real world primary care practice due to manpower shortages and to a fundamental incompatibility with fee-for-service reimbursement.

In large health systems such as Group Health’s, every dollar spent on implementing the medical home, $1.50 in savings was reported to be generated. Intangibles such as patient and provider satisfaction were improved. And overall, the quality of care was shown to be better than less organized or proactive methods of organizing care. None of which in and of itself is a bad thing.

But in spite of this, there is the compelling argument that such a model cannot be properly implemented without fundamental reform of the current financing structures presently in place in the US. In fact, reform proposals such as the medical home beg the question. While there are interesting elements contained in these models, this sort of local restructuring fails to address fundamental structural issues surrounding the underlying unfairness of the health care financing system--both from a reimbursement and funding perspective. Without some kind of universal health care financing scheme, as before, only select populations will derive any benefit from these innovations. The vast majority will still be faced with arbitrary, capricious market-based insurance manipulations that will continue to threaten many with inadequate coverage or bankruptcy even as their health care needs are most pressing.

On a personal level, I find it ironic that even as there is more and more talk of things like a patient centered medical home, there is no meaningful structural change taking place that might allow such measures to benefit patients across the board. As a result, I feel increasingly alienated from the unchanging chaos of US healthcare even as I simmer with anger at the ongoing manipulations of the political process by powerful entrenched vested interests in the insurance, pharmaceutical, hospital and medical care industries (which includes doctors) and the politicians who represent them.

I knew it was a risk, experiencing a functioning (even if imperfect) health care system like New Zealand’s, but I didn’t think I’d be left with this feeling of medical homelessness. It’s like returning home to an implacably fractious, dysfunctional, mean-spirited extended family after visiting distant relatives who live in a far more organized, harmonious, compassionate fashion.

I guess in retrospect that I shouldn’t be completely surprised. I met a few US doctors while I was there that had opted to relocate to New Zealand permanently to practice medicine. At the time I didn’t really understand what would compel them to take such committed action.

Now I do.

In fact, in an effort to better understand my initial exposure to the NZ health system, I have decided to return for a 6 month single site engagement--this time with my family--to take a more in-depth look. It’s hard to know what will come of it, but I feel that I have unfinished business there, and frankly, there is no compelling model of care--even in spite of some of the recent microinterventions--to fully engage me here.

An Open Letter to Tony Ryall, Minister of Health, New Zealand.

Dear Mr. Ryall,

It’s funny, everything here in New Zealand is so informal--up to and including patients and physicians calling each other by first names--that I almost feel like I should begin this letter with “Dear Tony”. After all, we met briefly at the rural general practitioners network conference in Christchurch in March and since then, I have been participating in New Zealand Locum’s “roving locum” program, so that would seem to almost count as the basis for informality in New Zealand. But I don’t feel comfortable with such a salutation. You have an important and honorable position and I would like to formally take a moment to give you some professional feedback and advice based on my 30 years in primary care and on my 3 months here in New Zealand.

Before we get started however, I must weigh in on the above photo. Maybe it “goes”, but I’m not sure all the stripes really work for you. Just a thought from a casual observer. But I don’t really want to go into sartorial issues with you, I think it’s healthcare that occupies us both.

From the very outset, I’d like to thank you and your fellow New Zealanders for affording me with the opportunity to participate in your care and become part of your communities, if only briefly. To say that the experience has been rewarding and reinvigorating would to be an understatement. I had the privilege of practicing in four different locations and I was uniformly impressed with the common sense, intelligence, industriousness, respectfulness, and dignity of the people I met.

In a broad sense, as part of your enormous political responsibility, you are tasked with caring for these people as well.

In recognition of that fact, I thought I’d share a few thoughts with you as to how I think you may better accomplish this lofty mission.

1. Continue to push for more primary care physicians and to generally support primary care, especially in rural settings. GP’s are the base of the health care delivery pyramid and if you look at almost any measure of health outcomes, countries that have a robust primary care network deliver better, more cost effective care. Your ROMPE program (rural origins of medical preference entry) is an innovative and proactive way to address the workforce needs of the country in the future. As is the Voluntary Bonding Scheme whereby students can benefit from debt relief if they practice in rural areas. And finally, your recognition that Integrated Family Health Centers may offer a means to provide more care for rural patients in the community setting is forward thinking. Anything you can do to further support and retain the hardworking GPs of New Zealand will benefit everyone.

2.Think about further modifications to or outright abolition of co-pays in the GP offices. To be frank, I’m not sure how you would do this financially, particularly given the philosophical approach that underpins the recently promulgated National Party budget. But here’s some food for thought: the preponderance of research shows that co-pays or upfront fees, particularly at the primary care portal of access, constitute an impediment to accessing care, especially for those who are most socially vulnerable. In three months, I witnessed several occasions when patients were actually turned away from a primary care practice for inability to pay upfront. Quite aside from the ethical quandary that this poses, it doesn’t make financial sense in the long run as patients are effectively shunted from cost-effective primary care to more expensive portals of entry such as the A&E department (ER).

3. ACC. Now this is a topic everyone loves the warm up to. I must say, that the ACC accident and compensation scheme is a brilliant way to fund and run a no-fault insurance program. It effectively almost eliminates litigation, and circumvents those who have a self-interest in fanning the flames of such. Unfortunately, because of the presence of user fees as discussed above, patients occasionally invoke an injury or accident to justify their physician visit. As with any type of insurance, the gray areas on the margins always seem to become a battleground. If New Zealand had a comprehensive bona fide single-payer system, like, for example, Canada’s, the need for differentiating an accident or injury from a medical problem would be obviated. Just a thought.

4.Procedure Wait Times. So as not to be repetitive I refer you to my recent blog post about this. (http://kwisecondopinion.blogspot.com). I just can’t help but think that a better approach to some of the unacceptable wait times in the public sector is to put more organizational effort, and yes, if necessary, money, into improving that sector of care. “Better, sooner, more convenient”, right? The tacit or surreptitious promotion of private insurance and private sector health care will ultimately prove divisive and uncontrollably problematic. You need look no further than the ongoing chaos in the USA for a harbinger of your future should you continue to promote this misguided approach.

5. Pharmaceutical policy. I would strongly encourage you to abolish direct-to- consumer advertising by the pharmaceutical industry--and for that matter, the health supplements industry as well, with their flagrantly unsubstantiated health claims. There is only one other country in the OECD that allows this sort of thing and again, I suspect that you would not like to be subject to the type or magnitude of political power and economic clout enjoyed by the pharmaceutical industry in the USA. Oh, and while I’m at it, please ask Pharmac to list drugs by their chemical, or generic names, rather than trade names in the published list of approved medicines. (Or has this been some sort of bargaining chip in the price negotiation process?)

I could go on, but those are pretty much the highlights of what I feel could be improved in the New Zealand health system at least from a primary care perspective.. Some of it, I know, it’s politically or economically untenable but that’s always what’s been said in the past about many reform proposals.

Probably most importantly of all, however, is that I simply wanted to ask you to be ever mindful of your responsibility to care for your fellow New Zealanders. Because even in the short time I was here, I was struck again and again by the fact that your fellow countrymen are indeed an extraordinary group of people. As the health minister for these people, you have a solemn obligation to care for them in the best possible way.

I wish you luck in this endeavor and I hope in some small way that this constructive feedback helps you attain that goal.

Best regards,

Ken Fabert, M.D.

"Better, Sooner, more convenient"..................But for whom?

Welcome to Medtral New Zealand. We are a Medical Tourism company specially set up by New Zealand physicians to provide people living in other countries with access to world-class surgery and aftercare in some of New Zealand’s leading private hospitals.

These high quality non acute medical procedures are available for significantly less than what they would cost in other developed countries such as the USA and Western Europe.

At Medtral New Zealand, we’re committed to ensuring the whole Medical Tourism process is as smooth and stress-free as possible. We handle everything for you, so you can focus all your energy on getting better.

Before your operation and while you are recuperating, you have the opportunity to enjoy some of the many pleasures New Zealand has to offer the international medical tourist

"Better, sooner, more convenient?"

That's the current National Party inspired catch phrase for improvement in the health sector. I heard it from the health minister Tony Ryall when he spoke in March at the rural GP conference in Christchurch. I see it as the title of the annual report of the Pinnacle General Practice Network, a PHO on the North Island. I see it frequently in the newspapers. But I still have to ask myself, why is the well orchestrated drumbeat of the slogan so pervasive? The simple answer is politics, but it probably also strikes a resonant chord with citizens and practitioners alike. The truth is that in New Zealand as with any other health system things are not perfect and the goals identified in the slogan are hard to argue with if they're pursued intelligently, honestly, and equitably.

But as you can see by the small blurb that starts this post, there's competition for health resources in New Zealand. The very first entry to my blog was a half facetious reference to my then upcoming roving locum experience as a new kind of medical tourism. Little did I know that the more questionable form of medical tourism had already taken root right here in New Zealand. Of course, the unapologetic entrepreneur would say "so what?". But I would argue that resources are indeed finite, particularly in a small country. And then there is the previously discussed issue of whether health care can even be regarded as a commodity.

What inspired me to reflect on this was the fact that today I had to write my first patient appeal letter to the departmental review boards who try to assign these scarce resources on a priority basis to patients in the public sector who need "elective surgery". This appeal involved an extremely robust dairy farmer who has now been waiting almost a year for replacement of a hip that has rendered him virtually unable to walk due to severe pain (in spite of attempts to control it medically, I might add). When I see for-profit businesses like Medtral, I'm reminded again that "money talks and nobody walks" (or in this case, you could say money talks or nobody walks...)

It's no coincidence that these sorts of entrepreneurial medical activities are occurring in New Zealand. For the past several years the new government has been quietly pushing its agenda to privatize components of the health sector and to encourage the purchase of private health insurance to gain access to expedited private services. Despite the sensible goals of the slogan, the cynic could be forgiven for pointing out the perverse political incentive to keep the public sector on the ropes. The longer people have to wait, the more attractive the "private option" looks.

All this from a government that just recently embraced a budget based on tax cuts and the increase of the GST, or consumption tax. Aside from being increasingly regressive-- the National Party could not even concede that a consumption tax on food is patently unfair -- this budget resurrects the historically discredited idea that tax cuts for the wealthy will somehow miraculously benefit all. In the words of Bryan Gould, a former vice chancellor of Waikato University, writing in the New Zealand Herald yesterday, "The evidence suggests that if the spending power of the wealthy is increased, it does not "trickle down" to the rest of us through greater investment and a keener eye for new opportunities, but manifests itself instead and more ostentatious and unproductive consumption."

Things like joint replacements for wealthy foreigners, while New Zealand taxpayers languish in pain.

I am not as unworldly as someone might conclude by reading the foregoing. I fully understand that the wealthy will demand and create goods and services that are far out of reach of real world people. The Saudi royal family will continue to fly from the Persian Gulf to the Mayo Clinic in MInnesota. Britain with its National Health Service will still have Harley Street, and the elite of Boston will continue to have a Harvard trained subspecialist for every organ system, the cost or practicality be damned. But in countries that are ostensibly democratic, there still needs to be a public conversation about the allocation of health resources and just how these resources are to be put to use.

For instance, Medtral touts the fact that New Zealand is "first world" and "English-speaking". Elsewhere on their website there is even talk about international awards received by New Zealand for being a peaceful place and having very low crime rates.

All these are attributes of a functioning of civil society, not some entrepreneurial endeavor. It is one thing to be proud of these social achievements but it's another to be benefiting from them while the citizens whose taxes and good behavior are the source of this state of affairs--the source of this positive social capital-- receive increasingly rationed care as a result of a politically and ideologically driven push towards increased privatization.

So no, things aren't perfect in New Zealand, but I still think egalitarian cultural traditions, a history of social cohesion, and a robust democratic tradition will allow the people here to address faults and shortcomings in a constructive manner and not be fooled by Reaganesque sabotage of functioning public institutions in favor of market-based illusions that benefit only the elite minority.

Smoke, Smoke, Smoke that Cigarette

Smoke, smoke, smoke that cigarette
Puff, puff, puff and if you smoke yourself to death
Tell St. Peter at the Golden Gate
That you hate to make him wait
But you just gotta have another cigarette.

by Merle Travis and Tex Williams

As my time winds down here in New Zealand and I prepare for my departure at the end of the month, I’m working hard on a few heavy-issue blog posts about topics like Maori/ Pakeha health disparities and New Zealand’s drift under the new National Party government towards some of the false solutions that resulted in the chaos that is American healthcare today. (Privatization, increased reliance on private health insurance, and judging by today’s new budget proposals and tax overhaul, tax cuts for the wealthy and the fallacy of trickle-down economics.)

But something else caught my eye in today’s Waikato Times, the daily newspaper from Hamilton. For the many of you who no longer read a daily newspaper and kid yourselves that you’re keeping up by grazing web-based content, this is another argument for sticking with print journalism. Today’s paper was full of good, juicy, healthcare related news. The front-page headline was “Patients’ Therapy on Track”, which catalogued the local Waikato DHB’s (District Health Board) progress in improving or attaining numerous health benchmarks ranging from immunization rates, wait times in the emergency room and access to elective surgery, to better diabetes and cardiovascular services. The good news is that the local DHB is doing better and better.

But what really grabbed my attention was one of the benchmark parameters called “better help for smokers to quit”. In NZ, there is real attention being paid to dealing with tobacco as a major driver of death and disability.

Digging even deeper into the newspaper on page 20 was another smoking-related article entitled “Tobacco Ban Rated Life Saver” which highlights a recent public health recommendation from the Otago University School of Medicine and Health Science, Wellington, that all commercial sales of tobacco be phased out by 2020.

I didn’t think that smoking would be one of my New Zealand blog topics, but it’s this kind of forward thinking that gets to the heart of effective public health intervention. After raising the pack price of manufactured cigarettes to over $15 New Zealand ($11 US) last month, a total ban is the natural next step in eliminating this health scourge.

This is a topic that has been near and dear to me ever since the start of my medical career in 1975, because I attended a private medical school in North Carolina called at the time, the Bowman Gray School of Medicine, which was affiliated with Wake Forest University in Winston-Salem, North Carolina, USA. And if you recognize the name of the city as two famous US cigarette brands, you’ll start to understand why I warm up to this topic. In point of fact, not only the medical school but the entire University was underwritten by the Reynolds and Babcock families of Winston-Salem, the owners of the RJ Reynolds Tobacco Co. I’m convinced that it was funded to assuage their collective guilt at profiting so handsomely from a product that so predictably and effectively kills people. It’s no coincidence that the medical school I attended was known for research in atherosclerosis and stroke. There certainly was no shortage of local patients suffering from these conditions as a result of their addiction to the local drug cartel’s product.

In fact, in the spirit of full disclosure, I didn’t escape North Carolina without being addicted myself. But after numerous attempts to quit I finally did and the only thing positive I can glean from the experience has been a credible understanding of what patients are going through who still struggle with smoking cessation. My all too intimate brush with the tobacco industry is also the source of the residual anger I feel at the lies, corruption, and blatant conflicts of interest that provided the institutional backdrop for my medical education.

Interestingly, the medical school has been renamed the Wake Forest University School of Medicine ( more whitewashing?) and to this day, they persist in sending me alumni updates and solicitations for financial contributions. I guess they don’t even read my responses to their solicitations because they keep sending me chirpy newsletters and they simply don’t seem to grasp that the institution is, to my way of thinking, forever ethically tainted.

But I am digressing. Back to the radical proposal: The blunt, get-to-the-point, common sense approach that I’ve come to expect from the Kiwis, comes through in a proposal simply to ban the stuff. In fact the thinking goes further. To limit black market trade, there is an endorsement allowing people to grow their own tobacco if they’re so motivated. It also helps that border control in an island nation is more enforceable than elsewhere.

Why are such measures important? Because young people are still very vulnerable to the glamorization and media manipulation that makes cigarette smoking “cool”. There is also a disproportionate number of Maori citizens here in New Zealand who smoke. Both groups would benefit greatly from significantly curtailed marketing of and access to tobacco. A manufactured tobacco ban would virtually eliminate the 5000 deaths that now occur annually in this country from cigarette smoking. This intervention alone is estimated by Prof.Tony Blakely at Otago University to be “the single most important and feasible action to reduce Maori mortality and ethnic disparities in this country”. Until 2020, additional phase-out strategies could include larger health warnings, a ban on tobacco displays in retail stores, no duty-free imports, and plain packaging (an intervention that Australia is seriously considering implementing in the near future).

It has now been over 15 years since I smoked my last cigarette, but in spite of that my cumulative lung cancer risk is still elevated. (But don’t tell my health insurance carrier, they might cancel me...) For me this issue is personal. Profit-seeking corporations like R.J. Reynolds tobacco sought to kill me with a toxic but “legal’ product. And I was young and stupid enough to think I was immortal or exempt. All the while, they and others like them continue to profit handsomely by peddling their lethal wares. And until now, the corrupt politicians from the killing fields of the Carolinas, Virginia and Kentucky defended the industry. It’s good to know that there’s one place where people are simply saying enough is enough. I truly hope the day will come soon (as I think it is already) when we view cigarette smoking as a bizarre artifact of the past.

Next up, now that we’ve touched on it, the reality of ethnic health disparities in New Zealand.

Where is the Pain?

Over the past 10 years one of the greatest burdens on US primary care physicians has become pain management. Since the mid-90s there’s been a steady drumbeat of academic opinion that primary care doctors are ignorant of and insensitive to their patients’ pain. It was an easy and seamless transition for the media and the pharmaceutical industry to transform this academic insight into an information and advertising campaign directed at increasing the demand for the prescription of chronic opioid pain medication. By the millennium it was not uncommon to hear from patients that doctors “don’t know anything about pain”-- often followed by demands for opioids,even followed by formal complaints if these demands were resisted.

But just what lay behind the academic assertions that primary doctors were not treating pain and that the drugs were falsely feared and underutilized? Assuming for a moment that there is no conflict of interest in the academic research world (a topic which Barbara Angel, M.D., a former editor of the New England Journal of Medicine has explored in disturbing detail to the contrary), the academicians may be forgiven for being stereotypically ignorant of real-world practice and the problems these recommendations have unleashed. after all they don’t see patients day in and day out in the community setting.

But for the marketing departments of the drug companies it was a very different story. Doctors were told, for example, that long-acting oxycodone formulations, the most heavily marketed of which was the now infamous OxyContin, were less addicting and less euphoria-inducing than once commonly feared. That’s certainly what the marketing team at Purdue Pharmaceuticals was telling physicians during their intensive marketing campaign. The problem was that Purdue had evidence to the contrary which it systematically suppressed. At least that was the verdict of a federal ruling which resulted in a $634 million fine levied against Purdue Pharma’s CEO Michael Friedman and his head Corporate lawyer Howard Udell when they were found guilty of intentionally “mislabeling” the drug. Those who followed this case closely, however, were disappointed that criminal penalties weren’t handed down because not only was OxyContin found to be addictive as result of its euphoria induction, but it was also implicated in a number of deaths stemming from these properties.

The problem is this: between the late 1990s and 2003, accidental poisoning, 90% of which was due to prescription opioid overdosage, became second only to motor vehicle accidents is the leading cause of accidental death in many communities of the United States. Thousands of deaths have been linked to the misuse, abuse, and diversion of prescription opioids, most of it prescribed for subjective non-cancer chronic pain.

There is little discussion about this today but just about any practicing primary care doctor will confirm that as a result of this upsurge in prescribing opioids for the treatment of chronic subjective noncancer pain, medical practice in the US has been fundamentally transformed. Significant time is now required for the monitoring, ongoing pain reassessment, and occasionally, dispute resolution engendered by the upsurge in the use of chronic opioids. When covering for a colleague, the situation becomes even more difficult. And clinically determining the treatment endpoint for a problem that often revolves solely around the patient’s subjective assertion of pain is often frustrating and difficult if not impossible.

The impossibility of the task is highlighted by the extent of the misuse of these drugs. In the Puget Sound region of the US, OxyContin sells for around one dollar per milligram on the street. Recommended chronic pain doses of OxyContin are 20 to 40 mg twice a day with doses of upwards of 60 to 80 mg twice a day for what the prescribing instructions provided by the pharmaceutical company terms “opioid dependent” users. Do the math. There are powerful black market incentives to divert and misuse these drugs. Why? Because someone seeking the euphoria produced by oxycodone can ingest 12 hours worth of oxycodone in seconds by pulverizing and snorting, dissolving and injecting, or crushing and smoking the drug. The abuse potential is enormous.

And how does my experience New Zealand compare with that in the US? In the four communities I’ve practiced in so far, the problem simply does not exist. Patients are more than happy to take a few days of codeine and utilize nondrug management such as immobilization for broken bones. They use ibuprofen or acetaminophen (called paracetamol here) for strains and sprains. And most astonishingly, many are happy to have an accurate diagnosis and prognosis as to the degree and nature of pain, and if it will be mild, they even respond positively to reassurance. And lest you think that I’m callous and uncaring, I have seen a few cases where pain issues were developing and it was addressed after adequate clinical assessment and a care plan was developed.

Are New Zealanders that much tougher than their American counterparts? I doubt it, but there is some recognition that a moment to moment pain-free existence (with euphoria on the side, if possible) is not always necessary or desirable. Could there be an urban versus rural difference? Admittedly, I have spent no time in large urban areas, but some of the highest levels of OxyContin addiction and abuse in the US have occurred in rural states like Kentucky Ohio and West Virginia -- -- so much so that the drug has acquired the moniker “hillbilly heroin”. No, I think it has a lot to do with expectations and, to come full circle, mistaken assertions and unconscionable marketing which has set in motion and continues to perpetuate this serious public-health problem.

And the solution in the US? Meaningful regulation and criminal prosecution of the executives of irresponsible pharmaceutical companies would have a great impact. (The $634 million fine was a fraction of Purdue’s profits and the executive perpetrators vigorously denied any responsibility for Purdue's policies-- blaming the victims, the doctors and the regulators for the problem instead). It also probably comes down to each and every physician taking a hard look at their own prescribing practices. After all, only we can sign the prescription. Helpful too, would be the expansion of detox facilities so that those who are addicted can be properly treated. Additionally,an honest conversation between physicians and patients about the perils of chronic opioids will also be needed. And perhaps most importantly, it will take a concerted education program at both the public health and individual patient level to remind us that pain is a symptom which compels a proper diagnosis as to its source and an exhaustive effort to correct the underlying problem by employing multiple treatment modalities of which chronic opioids are a last, not a first, resort.

Health Economics 101

In a utopian health system recipients of healthcare would enjoy no limitations on the three corners of the health system resource distribution triangle pictured above. Everyone would be able to get everything ---right away.

But of the three corners of this utopian health system, real world economics only allows you to have two of the three. Different systems make different choices:

• In the United States, for example, if you happen to be hyper- compensated corporate CEO, you can get anything you want immediately. But obviously this isn’t available to everyone. In fact the US seems to have consciously and comfortably chosen not to attempt to provide health care for all.

• In another system such as New Zealand, just about everyone can get everything, but it’s definitely not available right now.

• Developing countries like Vietnam offer everyone a modicum of immediate care but there are significant limitations on what is available.

• The final permutation of this health system resource triangle is what’s found in much of the impoverished world where very little is available to anyone ever.

I can actually think of no health system that even attempts to attain all three aspects of this triangle. And when you reflect on it, only the goal of providing care for everyone is without pitfalls.

Take for example, the immediate provision of care. I know of a patient in New Zealand who had deteriorating cardiac function due a heart valve problem. For her to obtain even basic diagnostic studies such as an echocardiogram and consultation with a heart surgeon entailed delay. During this time aggressive medical therapy (medicines) was undertaken and the patient was monitored closely. Over time, she responded well to medication and improved significantly, to the extent that surgical heart valve replacement was no longer necessary. In the US I’m certain that this patient would have undergone open-heart surgery and valve replacement sooner than later. It may still come to that in this patient’s case but it can be done in a measured, deliberate fashion. I am also convinced that had the medical therapy failed, there would have been enough elasticity in the system to move forward urgently with surgery. Sometimes immediately, while quite seductive, is not always the best approach. I frequently tell patients that time is a powerful diagnostic tool but for it to have its full impact there must be open lines of communication, a trusting physician -patient relationship, and easy access for repeated reassessment.

Everything can also have hidden costs. CT scanning, for instance, has become the standard in many emergency departments in the United States for assessing a multitude of problems such as abdominal pain and head trauma. There is now a growing awareness, however, that the significant amount of radiation delivered during CT scanning actually has significant carcinogenic potential. Well studied assessment and risk stratification tools such as the physical examination are often very much underutilized because of the clinician’s perceived lack of time and increasingly, a lack of understanding of or training in basic bedside clinical assessment.

The underlying principle behind the inability of any health system to satisfy all three corners of the resource triangle has to do with the fundamental driver of all economic activity: scarcity. Ultimately, resources are scarce and economic and ethical decisions must be made by any society as to how these resources will be allocated.

Just as important in health arena is the fact that demand for health services is what economists would term inelastic. Elastic demand on the other hand, is something that someone can forgo without significant adverse impact as price increases. An example of this would be dinner at a Michelin three-star restaurant or a Mercedes roadster. Inelastic demand would include such items as food and, of course, healthcare. A person with a burst appendix or the parent of a child with meningitis is simply not in a position to be concerned about price or, for that matter, quality comparisons in the way that the proponents of market-based healthcare seem to think.

The reality is that every society makes choices about their health system and the inevitable compromises that must be made. Relying solely on the false analogy of applying market principles to a perfectly inelastic demand curve with human rights and ethical dimensions simply makes no sense---unless you are a shareholder in a for-profit health insurance corporation. Economically rational solutions such as a single payer health plan have been systematically thwarted in the US and this betrays the extent to which the decision-making and implementation process have been a hijacked by a self-interested elite.

The recently enacted Obama “reforms” seem to have been a political necessity in the face of vicious right-wing attempts to destroy not only the health policy reform efforts but his very presidency. I fervently hope in the four years that will elapse before implementation of much of this legislation, there will be a more thorough, intelligent, dispassionate, and successful national dialogue about real changes that will benefit those who are still being left out of the lower right-hand corner of the triangle. We can do with less (maybe even stay healthier) and we don’t need everything right away, but the ethical and economic imperative to cover everyone will be the cornerstone of any meaningful reform.

The Ultimate Threat to Human Health

One of my chief diversions after putting in a 10 hour day at the Otorohanga Medical Center is reading. At present, I’m sampling a collection of posthumous essays by Bruce Chatwin entitled What Am I Doing Here. Like everything he did and wrote in his all too brief career, these fragments pulsate with creative energy and mischievious unpredictability. When I saw the title of this book, for example, my conventional instincts wanted to place a question mark at the end of it. But of course that’s not how Chatwin operated and just like the way he lived, his book leaves you somehow dangling and unsettled with the grammatical and punctuation tease of its title.

Let’s suppose for a moment, though, that there was a question mark. What am I doing here? What first sparked my interest in this place? I’ll leave the personal and existential aside and talk about the very first time my curiosity about New Zealand was piqued. I can pinpoint the date precisely because New Zealand appeared on my radar when then Prime Minister David Lange had the audacity to stand up to the United States military and forbid the entry of U.S. Navy warships into New Zealand waters if they were powered by nuclear reactors or carrying nuclear weapons. Of course official US reaction and response to this request was to refuse to confirm or deny the nuclear status of any given US warship. There then unfolded a steady deterioration in relations between New Zealand and the US which culminated in New Zealand’s expulsion from the ANZUS alliance in the South Pacific. Shortly afterward, in 1985, French secret agents blew up the Greenpeace ship Rainbow Warrior in the Auckland Harbour because of its stated intention to monitor nuclear testing by France in the South Pacific. This has been, as historian Michael King put it, the first and only act of state-sponsored terrorism against New Zealand.

As a result of this dedicated antinuclear stance in an era characterized by increasing anxiety about the growing possibility of nuclear confrontation occurring between the United States and The Soviet Union, New Zealand was held in high esteem by those of us who refuse to believe that nuclear brinksmanship is a rational way to conduct foreign policy or promote the survival of the species.

A few years later in the early 90s while living in Beaufort South Carolina, I was asked to serve on a CDC citizens advisory committee on the health effects of the Savannah River Site, which is one of the two US Department of Energy /Department of Defense nuclear facilities built to produce plutonium, highly enriched uranium and the hydrogen isotope tritium. (The other is on the Columbia River in Hanford, Washington). I was pleasantly surprised to come to the conclusion that there was no credible evidence of increased cancer incidence in the immediate area surrounding the Savannah River nuclear facility. Based on several tours of the facility, however, I found it chilling to see the sinister artifacts of the Cold War like decommissioned, but still radioactive, reactors and nuclear waste from that time forward that has yet to be dealt with in any remotely definitive manner. Of course, the most logical approach of all to dealing with this deadly residue, often with a half-life calculated in thousands of years, is not to produce any more of it in the first place.The hubris behind the assumption that present levels of containment and monitoring will be feasible over such inconceivably long time frames is mind-boggling and betrays an almost delusional optimism that present political stability will persist ad infinitim.

There doesn’t seem to be much conversation about this issue anymore. But there are still enough nuclear weapons located at the Bangor nuclear submarine base in Keyport Washington, less than 10 miles from my home on Bainbridge Island, to end human history. The macabre local joke is that Kitsap County which encompasses both Bainbridge Island and Keyport, is the world’s third-largest nuclear power. Sometimes it just seems a little surreal to fuss over someone’s blood pressure or sprained ankle virtually in the shadow of weapons whose sole purpose is to vaporize human beings by the millions.

And speaking of millions, the replacement cost of the Ohio class nuclear submarine pictured above (taken from my sailboat this spring in Puget Sound as I was compliantly changing course) is estimated to be upwards of US$4 billion. There are a total of 18 such submarines and service in the U.S.Navy. 14 of which carry a up to 24 Trident submarine launched ballistic missiles each with up to 12 multiply targeted warheads, etc., etc. Quite aside from the sole purpose and mission of these weapons, the financial outlay is staggering. In a perfect world this would purchase a lot of healthcare. Maybe it’s just the burden of empire, but just maybe it’s also a failure of imagination that keeps us from envisioning a future that embraces an alternative to mutually assured destruction and putting our resources to better use to improve the future, not obliterate it.

So good on ya, New Zealand, for barring the grey metal boats from your waters. Maybe this memorable act of courage will inspire other countries to also take a stand against the ultimate cynicism that underlies these weapons of mass destruction---potentially the ultimate epidemic.