Tuesday, October 20, 2009

Will more healthcare bring better health?

An awful lot of time and energy is being spent on finding solutions to our broken healthcare system. This  is justified, of course, given the unprecedented 16.2% of the GDP that it eats up, while virtually excluding 46 million people from participating through lack of insurance, and harming many through poor and defensive practices. But will focusing on these unquestionably important trees improve the forest of the nation's health? A nation that boasts unprecedented rates of obesity, diabetes and other chronic diseases? A nation 40% of whose citizens suffer from a chronic disease? A nation where 80% of the adult population pops at least one pill every day?

I am skeptical. And here is why. The Rand Corporation created this very interesting pie chart, quantifying the influences of factors responsible for premature death in the US.

Based on this chart, only 10% of all premature deaths will be avoided if we fix the access to and quality of our healthcare system. If we posit that avoiding premature death is our primary goal, then perhaps we need to be exploring other risks that compete with the medical care short falls. This scheme suggests that of the 70% of the causes that are modifiable (we cannot change our genes yet), 86% can be attributed to our social status, the environment around us and our behavioral patterns. Let's examine each one separately and see what conclusions we might draw.

Socioeconomic status (SES) is known to be the single most important determinant of health. SES determines not only where we live, but also what we eat, how much activity we engage in, and our educational opportunities. It is well appreciated that obesity rates are higher in poorer communities. Most shocking, however, was a report a little over a year ago indicating that, in the face of ever-increasing life expectancy in the overall population, life expectancy in the poorest parts of the US is declining. At the same time, the economic gap in the US is widening, with an unprecedented 6% of the wealth concentrated in the top 0.01% of the population. Further, since the mid-1970s, the real wages for the bottom 80% of earners have remained constant, while productivity has enjoyed exponential growth. And are we doing anything about this driver of health? We are continuing to outsource jobs, we continue to tolerate astronomical bonuses on Wall Street, all with the blind belief in economic growth, but in reality at great expense to the majority's welfare.

Environment is next. We have not only passed Hubbert's peak in oil consumption, but we have gone beyond the level of CO2 production, 350 parts per million, beyond which we threaten the planet with temperature increases that will not only alter our geopolitical balance, but also potentially bring us to the brink of extinction. Yet, much like the tobacco "debate" played out in the decades of the 20th century, we continue to drag our feet on climate change. Furthermore, we use tobacco tactics to cast doubt on the potential links between other man-made environmental contaminants and disease, confusing absence of evidence with evidence of absence of such a causal link.

And what about behavior? In the 21st century we are not talking about sex and substance abuse. In the 21st century the addiction of choice is the media. Children spend on average 7 hours per day glued to a screen, being unabashedly marketed to even while in school. Three major corporate conglomerates control the content of TV programming, telling stories not in order to promote responsible citizenship, but so as to create the perception of need where none exists, to drive consumerism and finally to generate the next generation of corporate drones with the single aim of ever-increasing productivity.

If it seems that we live in the Brave New World, it is because we do. The healthcare reform discussion, though necessary, is taking a lot of air away from other, equally as or potentially even more urgent concerns. The lather stirred by the opposition to healthcare reform is an effort to imbue this almost no-brainer populist need with a false controversy in the hopes that the hot air will distract the already apathetic nation from the worsening crimes of Wall Street against Main Street.

So, no, I do not believe that solving our healthcare problem will resolve out health disaster. The latter will need a more global approach to our runaway societal woes. A few posts ago I indicated that the market model of healthcare was a miserable failure. Today I have to conclude that unopposed market forces have promoted the failure of many, the success of a few, and have sold our Democracy to the highest bidder. Only by injecting humanist values into our society can we hope to get this ship back on course. If we don't, we are simply enjoying our final days of debauchery on board of this titanic.

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