Take A Listen
It’s September 2021, and the world remains in the grips of the COVID-19 pandemic. We didn’t want to be here. Global leaders assumed earlier this year that we would be past this thing by now. After all, we have vaccines that have the ability to severely reduce the rate of infection and seriousness of the disease. Logic says that once vaccines are available, infection rates should go down.
But that’s not reality, is it? Mamta Murthi, the World Bank’s Vice President for Human Development said just last month, “The situation that we see right now is absolutely unacceptable because a large part of the world remains unvaccinated and this is a danger for all of us.” Globally, approximately 27.6% of people have received at least one shot, but among poorer countries, including most of the continents of Africa and South America, the rate is something in the neighborhood of 1.1%. [Worldbank]
According to the CDC, the current 7-day moving average of daily new cases (153,246) increased 4.9% compared with the previous 7-day moving average (146,087). The current 7-day moving average is 123.6% higher than the value observed approximately one year ago (68,533 new cases on July 20, 2020). Children are getting hit especially hard this fall, and Idaho’s situation has gotten so bad that hospital officials there are having to make the difficult decision to ration care.
Against this background, having good health seems that it would hold an extreme amount of value. Not being sick, not being immunocompromised, being vaccinated, and having reliable access to healthcare arguably should be a desirable advantage that elevates one’s personal value enough that we would all desire to pursue it. Who doesn’t want to be healthy?
Yet, around the world, millions of people who have access to vaccines are turning them down. They’d rather take horse dewormer, which is proven to not only not work but to be dangerous when consumed by humans. As city and state leaders are once again talking about mask mandates, the same people who are unvaccinated are claiming that such public health policies violate their personal freedom.
This leads us to question who holds the responsibility for maintaining the value of health? Does it all fall squarely on the shoulders of each individual? Under that line of reasoning, it would be up to everyone to find their own cure to whatever ails them. Does the state have a vested interest in keeping the populace healthy? If so, where’s the line between dictatorial control and acting in the public’s best interest? What is the responsibility of the pharmaceutical industry, hospitals, and caregivers? Is it their fault when people die?
Knowing how socially and politically sensitive this issue is at the moment, I’m not going to pretend to be objective. If our aim is to base our decisions on the truth, then we have to disregard personal opinions and desires and look at hard definitions and verifiable truth. That may not play well with everyone reading/listening to this, but the life-and-death seriousness of the matter demands we disregard any discourse that does not meet the most rigorous tests of evidence. Pay attention. We have some terms to define.
Defining Health and Disease
I’m not sure anything is more fraught with danger than trying to put a definition onto the various terms around health and medicine. In fact, the lack of consensus is a bit frightening. If people of science can’t agree on the definition of disease, then how are they going to efficiently develop medicines to address those diseases? Obviously, someone’s getting something done, but the overall argument continues.
Here’s the general take: Health is the absence of disease. That sort of makes sense, doesn’t it? This perspective assumes disease is an internal state of some manner of dysfunction departing from normal functional ability. “Normal functional ability” in this sense is when a body part (organ, muscle system, etc.) is operating within statistically typical ways to secure the survival and reproduction of an individual. [Christopher Boorse, 1997] Most people are ready to jump behind that definition and move on.
There are some issues with going in that direction, however. Notably, the definition fails to take into account the values that shape judgments around what is or is not healthy. If we were having this conversation a couple of hundred years ago, masturbation and homosexuality would be considered diseases. That clinical definition did not change until the latter half of the 20th century and when it did, it wasn’t because there was any biological or natural change in the human condition, but rather one of subjective opinion. [H. Tristam Englehart, 1974] That there are still some in the medical community who would hold to the antiquated definition is rather disturbing.
Another issue is that biology itself does not provide a definition of what is the “natural state” of anything. We might examine statistical norms for things like liver function or kidney efficiency, but a global average range fails to firmly establish what is “normal” because that average range might well shift from generation to generation without any obvious cause. This “naturalism” definition of health also assumes that physical fitness is everyone’s goal and that therefore medicine should be geared toward bringing us closer to that goal.
Now, let’s shift for a second, and flip the dictionary. If we can’t agree on a definition of disease, can we agree on a definition of health? The World Health Organization makes such a definition in its preamble: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Hello, ambiguity, anyone? This definition creates a quality of life argument that varies from one culture and social structure to the next.
Let me bring this home a bit. Four years ago, at Kat’s insistence, I went to the doctor and they checked my blood sugar levels. My A1c, which is a three-month average of one’s sugar, was 7. The doctor warned me that I was pre-diabetic and told me to come back in three months. Those three months came right at the end of the fashion season, during which I would normally consume high amounts of chocolate and donuts in an attempt to keep myself functioning as we ran from one show to another. So, when my A1c was checked a second time, it was over 10, which is well into the danger zone. Ideally, one’s A1c needs to be below 6.
Boom. Life change. Bottles of medicine filled the shelf on my desk. Dietary change became necessary. When I went back six months later, my A1c was 5.6. The doctor said that was a wonderful recovery and that I could treat myself occasionally. That turned out to be bad advice. “Occasionally” is too random a definition and I have a thing for donuts. So, I changed doctors, and when I finally was able to check again, my A1c was back up to 7.8. Too high.
We switch up the meds and since the pandemic interrupted my ability to have my A1c checked regularly, I started monitoring my blood sugar levels at home. When I was finally able to return to my doctor last week, my A1c was back down to 5.5.
That’s good news, right? Sure, to some degree, but defining diabetes solely on the measure of a particular moment is misleading. My doctor was careful to remind me that diabetes is a progressive disease and that no matter how carefully I manage it now, eventually, I will still end up blind and probably unable to walk. Whether that happens when I’m 70 or 90 depends as much on my personal behavior as it does on the medicine I’m taking.
The progressive nature of diabetes is why it is on the federal government’s list of disabilities. No, it doesn’t mean I automatically qualify for disability insurance or that I get special parking privileges. It does mean that my health insurance is higher and that anyone hiring me for any reason gets credit for employing a disabled person. I don’t consider myself disabled. My doctor does not consider me disabled. In fact, my doctor thinks I’m surprisingly healthy considering the long list of diagnoses that would seem to indicate otherwise.
Are we beginning to see the problem? Medical definitions affect people’s lives, determine what type of care we get, what insurance will pay, and how we are treated by society in general. Yet, those definitions are frequently less than accurate which makes the matter of determining the value of our health extremely complicated. Valuation relies on more than just definitions, though, and the complications are just starting.
Who Gets Good Health?
Regardless of how sickness and disease are defined, the value of healthcare depends in large part on who gets the sickest the most often. This brings us into the sociological field of population health, where the consideration is the health and outcomes of a specific group, whether that be a neighborhood or a nation. Population health is important for a number of reasons: When we observe diseases occurring within a specific population we are better able to identify the cause of that disease and work toward a treatment or cure. Population health also allows us to look at conditions that predict or increase the chances of someone getting a disease so that preventative care can take place. And then, population health allows us to see which diseases are the most widespread so that we can devote funding and research to the diseases that are affecting the most people.
Talking about population health can get dicey in social settings because it uncovers some of the realities of health and healthcare that reveal privilege and bias along racial and economic lines. If that makes us uncomfortable, then perhaps that is a good thing. If we’re uncomfortable to a sufficient level, we’re more likely to take steps to correct the situation.
For example, studies in 2005 confirmed that black people are sicker than white people in the United States and it’s not because of economic conditions. The National Academy of Medicine (NAM) found that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable.” Black people are simply not receiving the same level of healthcare as white people do, and the reason is strictly one of racial bias. [Source]
In 2015, Dayna Bowen Matthew tackled this problem head-on in her book, Just Medicine: A Cure for Racial Inequality in American Healthcare, Focusing on implicit bias as “the single most important determinant of health and health care disparities,” Dr. Matthew argues that “We will continue to utterly fail in the effort to eradicate health disparities unless we enact strong, evidence-based legal remedies that accurately address implicit and unintentional forms of discrimination, to replace the weak, tepid, and largely irrelevant legal remedies currently available.” She lays out a solution that involves implicit bias testing for physicians and critical healthcare workers, as well as changes in laws so that there is stronger responsibility on the part of healthcare providers to explicitly look for and address these biases where they occur. Sadly, those reforms are getting a lot of pushback from physicians who claim, “We’re not racist! You don’t know what you’re talking about!”
We also have to deal with social impacts on healthcare. According to data released this past July from the Organization for Economic Cooperation and Development (OECD), social protection against the economic impact of healthcare in the United States is painfully low at only 37.3 percent in 2019. This compares to the countries such as Canada, Australia, Denmark, Finland, Ireland, Israel, Italy, Japan, Korea, Portugal, and the UK, which cover 100% of healthcare costs for their citizens. In fact, of the 38 countries participating in the OECD study, the US is by far and away the lowest in terms of social protection against healthcare costs. The next closest is Mexico at 72.4 %, more than double the US. Everyone else is higher. Everyone else is doing better.
In a strong nationalistic environment, one might be inclined to ask what difference does it make if healthcare costs are subsidized by public versus private or voluntary entities. The answer likely comes in the form of a disturbing mortality statistic: Americans die sooner than their European counterparts. This isn’t a new statistic. We’ve been in this precarious situation for over 30 years and have yet to make a significant change in the gap. In fact, over the past two years, we’ve slipped even more.
In an article for The Atlantic this month, Derek Thompson outlines the severity of the problem. No matter how one slices the demographic pie, Americans are behind. “American babies are more likely to die before they turn 5, American teens are more likely to die before they turn 20, and American adults are more likely to die before they turn 65.” While European life expectancy is over the age of 80, American life expectancy has never crossed that threshold. We have more gun-related deaths. We have more automobile-related deaths. And our infant mortality rate is so pathetically low we should be embarrassed.
Thompson’s article also points out that in Europe there is little difference between the mortality of poor and rich people. No matter what area one considers, the rates are virtually the same across the board. Not so in the US. The wealth gap as it relates to health and mortality is severe. Even with COVID-19, we’ve seen a significantly higher number of deaths among poor and black communities in the US, a statistic that doesn’t even exist in Europe. When you look at things ranging from heart disease to diabetes and, most tragically, infant and maternal mortality, poor counties in the US fair far worse than rich counties, leaving a clear demarcation that shows our prejudices, biases, and systemic shortcomings within the healthcare system.
We can say that we value health and healthcare all we want, but there’s no denying the shameful and embarrassing numbers. For all the talk, Americans don’t seem to put much value into being healthy at all.
Five A’s of Healthcare
In 1981, Roy Penchansky and J. William Thomas defined the five things necessary for healthcare to work and actually keep people healthy. Those five things are:
All five are important and the concept of health loses significant value if any of them are missing. Let’s break them down just a bit.
Availability is having a trained provider available in a community when they are needed. Seems pretty simple, right? And as recently as 2018, the CDC claimed that there was sufficient availability for 87% of the US population, which, while far from perfect, is better than several other places on the globe.
Then, the pandemic hit. Hospitals have been overwhelmed as waves of the virus wax and wane. Most healthcare providers consider this most recent wave to have been preventable, something they find frustrating to the point that their compassion for patients has fallen off considerably. Exhausted doctors have been retiring in droves and weary nurses have either moved into home healthcare or left the profession entirely. The World Health Organization estimates that by 2030 there will be a shortfall of qualified healthcare workers to the tune of 18 million people. With more urban hospitals having to hire traveling nurses to fill gaps in their rosters, rural hospitals, which often can’t afford to pay the higher salaries, are losing nurses and leaving rural counties without options.
Of course, if more people were getting the vaccines, there would be less need for such a high rate of availability, but as one doctor put it, “people will reject science right until the second they need everything I have to keep them alive, and then they feel that they can come to our door and be entitled to that help and that hard work.”
Access may be one of the most talked-about issues in healthcare. This was Penchamsky and Thomas’ primary focus and it has been a driving point of healthcare legislation for the last thirty years. Access means that people can get the appropriate resources they need to preserve or improve their health. [PubMed] This goes a step beyond the availability issue.
The Office of Disease Prevention and Health Promotion (ODPHP) addresses the issue of access by quantifying the primary barriers: “Inadequate health insurance coverage is one of the largest barriers to health care access, and the unequal distribution of coverage contributes to disparities in health. Out-of-pocket medical care costs may lead individuals to delay or forgo needed care (such as doctor visits, dental care, and medications), and medical debt is common among both insured and uninsured individuals. Vulnerable populations are particularly at risk for insufficient health insurance coverage; people with lower incomes are often uninsured, and minorities account for over half of the uninsured population.”
These are not new issues. In fact, healthcare access was a frequent debate topic when I was in high school and that was when most of today’s doctors and policymakers were still in diapers. Nothing on that list of barriers is surprising. What’s disturbing is that we’ve not done more to eliminate those barriers. Sure, the Affordable Care Act helped a little, but circling back to OECD study, we’re still falling far behind both developed and developing nations, which is really, really embarrassing for the richest country in the world.
Accommodation primarily applies to people with disabilities. In fact, the whole purpose of the Americans with Disabilities Act (ADA) is to make sure that disabled people can integrate into every aspect of society. This means having ramps or elevators for those who can’t take the stairs, having bathroom doors wide enough for a wheelchair to fit through, and reserved parking which seems to upset able-bodied lazy people more than anything else.
Accommodation also addresses issues such as providing transportation to and from doctor’s visits, rehab, and physical therapy facilities, and the provision of any medical equipment to help keep a person alive. These are just a few of the matters that make all the difference in the world for people with moderate to severe disabilities.
Yes, there is some abuse of the ADA. For example, if I were employed by a company that routinely provides danishes or donuts at meetings, I could make a big stink about them needing to provide a sugar-free alternative as well. Good luck with that. I’ve been looking for sugar-free donuts for four years with no success. But according to ADA guidelines, the company would need to either provide an alternative snack or eliminate their presence altogether. If the company chooses the latter option, then everyone is upset and I’d become the office bad guy for causing everyone to lose their danish and donut fix.
Consider the challenge of people with peanut allergies. In some severe cases, simply being in the same room with peanuts could be problematic. Accommodating those needs and the needs of everyone the ADA considers disabled, can be expensive and time-consuming.
Accommodations go beyond addressing disabilities, however. Making sure everyone is kept safe and healthy is a part of being accommodating. Smoke-free environments are probably the most prevalent example. During the pandemic, accommodation guidelines mean hospitals have to provide doctors, nurses, and other staff with sufficient protective covering as well as a reasonable place to relax without needing those coverings. [Bloomberg Law] The whole issue is a complex and complicated mix of medicine and law that is difficult to comprehend.
Acceptability is perhaps the most critical issue we’re facing in this pandemic. Acceptability addresses a patient’s satisfaction, comfort, and trust with the healthcare they’re receiving. For example, many people prefer seeing physicians of the same gender as themselves because if you’re going to have to get naked for an examination, you trust a person of the same gender to not take advantage of the situation and do something creepy. If a doctor hands you a prescription for medicine and says, “You need to take this or you could die,” you have to trust the doctor, the pharmaceutical industry, and the pharmacy in deciding whether to actually take the medicine.
Most of the time, acceptability has not been a widespread issue. You see your doctor and do what he says, at least, until another doctor tells you to do something different. The example that sticks in the back of my mind is the problem one of my aunts faced when being treated for cancer. Her oncologist insisted she needed chemotherapy. But chemo was really rough on her, as it is almost everyone. So, when a chiropractor told her that he could “cure” her cancer without chemo, she stopped listening to her oncologist and started going for regular chiropractic treatments. By the time she realized her error, it was too late for chemotherapy to stop the advance of the disease and she died soon after.
With the pandemic, however, distrust was embedded into the public discourse from the very beginning. The now-former president told us the virus would go away quickly. It didn’t. He told us it wasn’t a big deal. It is. He touted questionable and unproven remedies over the recommendations of health officials. He was wrong. As a result, when the situation reached a critical stage where shutdowns and mask mandates were necessary, there was a severe lack of acceptability by roughly a third of the US population. When the vaccines were released, that same lack of acceptability continued and as the Delta variant has unleashed a new wave, those who didn’t accept the medical advice are dying. 95% of hospitalizations and 99% of deaths in the past month can be attributed to this lack of acceptability.
The difference between my aunt’s situation and the pandemic is that my aunt’s lack of acceptability only affected her own health, not anyone else. While her family grieved at her passing, she was the only one who died. With the pandemic, failure to trust and accept medical opinions not only affects the individual but everyone who ever comes in contact with those individuals. The lack of acceptability has created a public health crisis where one didn’t need to have happened.
Then, finally, there’s the matter of Affordability. I don’t think we need a lot of explanation for this one. Bottom line: healthcare is not affordable. If we all had to pay the doctors and hospitals out of our own pockets, it would create an economic disaster. If we all had to pay for our own insurance, most of us would have to do without. Again, this was supposed to be addressed by the Affordable Care Act; it’s in the name. Yet, the reality is that there are still millions of people without insurance and even for those who have insurance, a major illness can be economically devastating.
There was an anecdotal account two years ago, which I’ve been unable to fully verify beyond the certainty of the woman’s passing, where a woman was diagnosed with cancer. She had top-rated insurance through her employer so one would assume everything would be taken care of. It wasn’t. Once she got sick, she could no longer work, cutting the family income in half. Once her sick leave from work ran out, she was fired and lost her insurance. The cost of replacing the insurance through COBRA was prohibitive. She and her husband maxed out all their credit cards, cashed in IRAs, utilized every dime of their savings. By the time she died ten months later, her 71-year-old husband was left to survive on less than $2,000 a month and facing a mountain of medical bills for which he is held responsible.
Are we really putting any value on good health if we can’t afford good healthcare? We know we have a problem, but the argument over how to address it is helping no one.
All Hat, No Cattle
People in the United States like to talk about health and fitness and medicine. A lot. There are over 50 print magazines devoted to the topic and I can’t count all the websites devoted to the topic; it could be in the millions. But for all the talk and hype and claims that we value our health, we’re not really all that healthy, are we? Our actions are contrary to our diatribes and the end result is that among developed nations the United States may be the least healthy of them all.
Growing up, we had a term for people who would drive around town in big pickup trucks, 10-gallon hats, and boots that never saw a speck of dirt. We said those people were all hat, no cattle. They liked talking as if they were farmers or ranchers, but the truth was they had cushy office jobs and only looked at cattle through the windshield of their shiny trucks.
Americans are much the same when it comes to our health. Judging by how we talk, our advertisements, our favored media personalities, one might get the impression that we all spend two hours a day in the gym, eat little more than leafy greens, and carefully monitor our health. The reality is that the US is the most obese developed country in the world (only a handful of small island nations rank higher). [Source] 36.2% of the population has a body mass index over 30 and while BMI should never be the only consideration in determining obesity, it is an important marker when looking at population health. Roughly 78 million adults and 13 million children in the US have to deal with both the physical and emotional challenges of being obese.
Obesity is a health crisis in the US. [USNews] Our mental health is also in crisis. [APA] Racism is a public health crisis. [Altrum] In fact, by some accounts, the US has spent the past 50 years careening from one health crisis to another. [Health Affairs] In 2014, the CDC stated that as much as 40% of annual deaths were preventable. That was pre-pandemic. If we add the number of non-pediatric COVID-19 deaths since April, when vaccines were widely available, the number grows embarrassingly larger.
Full stop. Have you noticed how many times I’ve used some form of the word embarrass this week? Maybe because of everything we’ve discussed so far, this is the one we’re failing the most and we’ve absolutely zero room to claim ignorance. We’ve known about this problem for a long time. We’ve studied the solutions until we’re blue in the face. We know what we need to do, but we stubbornly refuse to do it on both personal and national levels. So yes, it’s embarrassing!
I can take care of my part. You can take care of yours. But the level of public health beyond the individual is massive and there are a lot of people talking but few actually doing anything. NO ONE is making a substantial difference at the federal level.
We have a choice. Either we start putting some action behind our words and make health a national priority, or we stop pretending that we value our health because, as it stands now, we don’t. To say that we do is a lie and no one likes a liar.