Friday, August 27, 2010

Why medicine is not like groceries

When I was in training as a Resident and a Fellow, I remember taking only a couple of sick days over the entire 6-year period. And I had to stay home because I could not stop praying to the porcelain Goddess during a bout of a particularly nasty flu, despite a vaccination. I actually took pride in my health record, and attributed it directly to being rather sickly as a child. Well, not really sickly; I just contracted all of the childhood illnesses that prevailed at the time in my geography.

Yes, I spent my childhood in Odessa, Ukraine, where I got vaccinated against polio and smallpox, but not against measles, mumps, rubella, chicken pox, whooping cough or any other diseases that our children in the West will never contract. So, every couple of months I would succumb and have to stay home with a fever and a rash, and my mother would call my pediatrician who would come and visit me in our home promptly to examine me and, most of the time, reassure my mother that I would likely survive this time. And then, at the end, I was promptly seen at the clinic to be sure that I had recovered completely.

This is why Dr. Gaulte's entry on KevinMD got me thinking. I know that we have a hard time seeing shades of gray, but see them we must. Even if something seems bad to its core, some things about it may not be horrible. For example, we can argue whether home visits are the most efficient way to practice medicine, but we cannot argue the fact that healthcare in the USSR afforded me access to this primary care service. As it afforded it to every citizen, child or adult. Yes, I am thankful that I did not require any serious life-saving interventions, as those would surely have been either unavailable or substandard. But then again, why should the need for heroics be the rule and not the exception in a relatively healthy population? Should we not instead throw our energies into addressing common things? My point is that, despite its many undisputed flaws, the socialized medicine in the USSR provided access to a healthcare system when it was needed, albeit not one that I would want if I required some state-of-the-art intervention. But again, the vast majority of a reasonably healthy population should not routinely require high technology medicine. So, a modicum of access to a reasonable system is not something to sneeze at. Take it from someone who lived it and did a lot of sneezing. And lest I be misquoted, I want to be very clear that I am not in any way advocating emulation of the Soviet style system, but merely pointing out that some things about it were not all bad. Just as some things about our catastrophe-focused system are not all bad. What is needed, as always, is some middle way.

Another point about the post. Comparing healthcare access to food? As already pointed out by a commenter, our food system is far from an example of free market success, as it is heavily subsidized by our tax dollars. Of course, one can argue that this centralization of food production has been a huge environmental and health disaster for our nation. So, this would appear to be an argument for decentralizing everything. If only healthcare were as simple as food... 

Food happens to be a very bad analogy for our healthcare system, and here is why. Although we now indulge in high-technology food engineering, the reality is that food is a simple enterprise. If one has access to even a small plot of land, virtually anyone can produce their own food. As an example, people in cities and suburbs are beginning to raise their own back-yard chickens, and community gardens are springing up in large urban centers. If one cannot grow his/her own food, farmers' markets are making a big comeback, and not just in rural areas. These locally grown healthy alternatives to mass-produced E. coli and salmonella-contaminated products are inexpensive, and many farmers are willing to barter their wares for services and products that customers can offer. So, food, while necessary for survival, is fundamentally a low-tech enterprise. Along these lines, one could compare food to medicine, but the medicine prior to the Industrial era, when technology was non-existent and our doctors and farmers had far more similar business models. A doctor was a part of the community, there were no $10,000-a-week treatments, and bartering was acceptable in the doctor's office. Today's impersonal behemoth healthcare system with its fancy shiny and expensive gadgets, coupled with reimbursement rates in direct proportion to higher technology utilization, can hardly be compared to authentic food production. Simply put, while almost anyone in theory is able to access good food cheaply (the fact that we choose not to does not impact this point), no such possibility exists in the current healthcare system in the US.

Well, time to summarize my ramblings. 
Point #1: Not everything in an evil system is evil. It is useful to recognize paradoxically good points and see whether and how we can apply them to our situation. 
Point #2: Comparing access to healthcare to access to food is sophomoric at best, perpetuating a false analogy.
Point #3: Can it be that Roemer's rule is at play in our entire healthcare system? That is, since we have built a system for catastrophic health crises, now catastrophic health crises must be the rule and not the exception?
Think about it. Tell me if you think I am correct or completely out in the left field.            


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