Health Care Provisos

I think one’s occupation tends to encourage a tightly focussed view of only one lane on the road, and a trust that it and it alone will lead to the intended destination. In my hitherto tunnelled vision, it had always been the Medical Model that dominated -to the exclusion of any rival Magisterium. But as time matures, I have come to realize that what makes you well has less to do with Medicine than life style, apportioned genes, good luck… The doctor plays only a minor and maybe incidental role in the spectrum that is a healthy life. Health care, then, is not only ‘doctor’ care, or ‘nurse’ care, or even hospital care -it is Society care.

Is our currently extended life expectancy the result of doctors and technology? Partly, no doubt, and yet of all the six billion or so people now extant, how many have been saved by organ transplants throughout the world? How many by dialysis? How many spend time in an ICU? It is an insignificantly small fraction of humanity and yet in many -most- countries we are living longer. I would submit that this is a result of better sanitation, better hygiene and better nutrition -as well as better doctors…

It’s interesting to me that one could correctly attribute several causes to, say, tuberculosis. There is the one we doctors seem to prioritize: the tubercle bacillus. And yet although it may qualify as a necessary cause -a sine qua non for the disease we label TB- is it a sufficient cause? If I have a positive skin test for TB but do not have the disease, and yet the poor homeless woman begging on the corner with the same positive test does, why is that? One could be forgiven for wondering if TB is caused by malnutrition, overcrowding, or poor hygiene -poverty, in other words.

For health ministers, QALYs (Quality Adjusted Life Years) have been in and out of vogue for a while now.  I do not pretend to understand all the intricacies of their assignment, but the concept does seem a bit too heavy on John Stuart Mill’s Utilitarianism for me. Let’s say, for example, you give a person in a wheel chair only 0.5 QALYs because of her limited mobility -compared to a ‘normal’ individual (who gets 1). Doing a renal transplant on her would still not result in the same number of QALYs for that treatment that you would get if you transplanted a kidney into an otherwise ‘normal’ woman because no matter the new kidney, she would still be in the wheelchair… So if you were trying to utilize those scarce resources to maximize QALYs, who would you pick? And would that be fair?

On the other hand, there is the theoretical ‘black hole’ phenomenon that political bioethical philosopher Jonathan Wolff describes: if you were to spend all the health care dollars on the worst off or the most needy, it would not much benefit the rest of that society who also have needs -and it would consume the entire budget as well… The compromise, of course, is to prioritize the most needy and yet acknowledge others in the resource allocation… And consider additional needs that at first glance, might seem peripheral to wellness.

What am I getting at? Well, it has been suggested that an alternative to throwing all the limited resources even a rich society has available for health care at the ill (traditional health care provision, medicines, new and expensive technologies) would be to spend some of it on improving housing and opportunities for the poor -the proverbial ounce of prevention… The ultimate cost of preventing illness would be less than having to treat it. So: affordable housing; education; the provision of contraception for women in situations where they might wish or require it; new vaccines instead of (or at least in addition to) new medicines to treat the diseases they might have prevented; affordable daycares to allow single mothers to work, decent minimal wages; provision of breakfasts and lunches at inner city schools for disadvantaged children… The list is even longer of course, and yet it is cheaper than the alternative in the long run.

We have to get away from the idea that Health Care is just treating illness, visiting clinics, or getting tests. It is an attitude of caring and providing sustenance for those in difficult circumstances; it is anticipatory intervention long before the overt manifestations of sickness or disease. It is the recognition that illness can arise as much in the situation, the milieu, as in the body. John Steinbeck summarized it well, I think: A sad soul can kill you quicker than a germ.

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