On serving the Underserved as an incredibly privileged person

Prior to starting medical school, I was a research assistant in a pilot program, a multi-disciplinary assessment of community reintegration in people diagnosed with HIV and recently released from incarceration. My job was to conduct detailed psychological interviews and perform neuropsychological testing in order to establish history of trauma, previous psychiatric and psychological treatment, and any cognitive challenges patients faced. I had expected the project to be challenging, but I had not anticipated the depth of my own emotional reaction. This project would set in motion my understanding and subsequent commitment to social justice. It would highlight the necessity of responding to suffering, which includes not only caring for individuals but also combating systemic barriers to health and human flourishing.

My patients felt they had paid their debt to society, but society would not give them a chance. Most had limited education and job training, and during the recession, it was difficult enough to find a new job without a conviction. Prior to incarceration, many had suffered mental illness, including substance addiction and depression. All of them now faced complicated HIV medication regimens and doctors’ appointments despite frequently unstable housing, transportation, and employment status. After release, many met criteria for devastating post-traumatic stress disorder, some resulting from horrifying events occurring while under the “care” of the State. Almost all were from poor backgrounds and the majority were people of color. During the interviews, many expressed themes of detachment, a sense of alienation from society starting in childhood. Some intimated a sense that outcomes many Americans view as basic rights or inevitabilities were never options for them, like freedom from an abuser, a safe home and school environment, or deciding what to be when they grew up.   

How do we interpret and respond to another person’s experience outside of our own perspective? When we consider the background of ourselves and our peers, perhaps even the process of becoming a health professional could be a hindrance to meeting the needs of the Underserved. Consider: to even become a doctor almost demands that we are from a background where adults took time to read to us, encouraged our intellectual development, loved us, and met our needs. Without emotional and financial support and some degree of stability, it would be impossible to achieve the sustained academic excellence required to even gain acceptance to medical school. We are told that we are here because of merit, when the reality is far more complicated.

We are taught to feel negatively toward those who have committed crimes, yet most of us do not understand the complex criminal justice system, including how we decide what a “crime” is and is not, how we determine its punishment, and how incarceration affects not only the individual’s psychological and physical health, but that of their families, their friends, and our entire society. People don’t commit crimes in isolation of social influences. The medically Underserved do not exist in a vacuum of poor decisions and bad luck.

What if our way of life has necessitated an underclass, and all attempts to attend to their medical needs are stopgap measures?  

For me, the process of dedication to attending to the needs of the Underserved has been continuous and ongoing, requiring learning and re-learning, questioning, research, and learning about the history of my own privilege. My work with individuals has informed understanding of the effects of a profit-oriented medical system that is incentivized to treat disease instead of promote health. This is in the context of a short-sighted economic and political environment that values the accumulation of capital and wealth to such an extent that even its pursuit is an act of violence against the poor.

On an immediate level, meeting needs of the Underserved involves helping individual patients develop self-efficacy while also helping people learn to meet challenges as a community. These are skills that must be promoted in medical and other health professional schools; it is much easier to tell patients what they need to do than it is to figure out why they aren’t already doing it, especially in a time where patients will often come in having googled symptoms, diagnoses, and treatment options. As healthcare professionals, we must unravel the previous paternalistic view of physician-as-expert. We are partners in promotion of the health of our patient, who visit us in recognition of the training we have undergone to provide medical knowledge and perform procedures as safely as possible, free from the influence of those who simply view the provision of healthcare as a commodity to be bought and sold.

Some illnesses and treatments are so well-established there is an actual algorithm for what medications to prescribe. Diagnosing and treating high blood pressure comes to mind. While there is still a need for a careful history and physical exam to rule out other causes, many people could read the JNC-7 report and figure out what blood pressure medication they should be taking. Some have criticized that our move to evidence-based medicine instead of intuition, prior practice,  and “expert”-based medicine has taken the human element out of care. A recent study provided some evidence that artificial intelligence can apply treatment rules better than doctors and with better outcomes! What will be the role of medicine as these technologies are further developed? Will there even be one? I think there will be; human behavior is much more complicated than knowing what one should do and simply doing it. I am interested in how contributions from the fields of positive psychology (the study of human flourishing) and behavioral economics (the study of how people make choices) may inform the practice of medicine.  The human element of the patient-physician relationship provides room for encouragement, some accountability and motivation, and identifying other barriers the patient may not have considered. To be a good physician requires training developing these skills. Yet it is not the primary focus of current medical training, which overemphasizes memorization of scientific facts. Knowing the specific enzymes and substrates in the cholesterol synthesis pathway may help us understand how cholesterol-lowering medications work, but choosing a medication for a particular patient is often based less on how it works, but more on how well it works and its side-effect profile.

On a broader level, helping the Underserved demands recognition that all people’s struggles are related. It requires the development of an empathic mindset starting in childhood.Maybe it means that terms like “Underserved” are themselves divisive and kind of perpetuate themselves without solving the problem.

When it becomes especially challenging and seems overwhelming to address all injustices, it might be helpful to try doing something like a silent prayer: May we be able to recognize the common vulnerability to disease, suffering, death that all people share.

 

Market-based ideas: option or coercion?

I recently saw the new film Escape Fire and felt like it provided a pretty good introduction to the problems with American health care at the moment. It was up to date in detailing why Obamacare is an imperfect solution, and it did explore the issue of why for-profit corporations might not be in the best position to reduce health care costs. Just because of the wide variety of issues the filmmakers chose to look into, it was naturally limited in the depth it could go, but it seemed to provide a reasonably fair assessment overall.

I was struck by one example of lowering costs and improving health that I hadn’t heard about before – that of the grocery store Safeway. Faced with rising health insurance premiums like most companies, Safeway decided to implement a behavioral motivation program where it based the costs of its (non-union) employees’ premiums on a variety of health indicators: “tobacco usage, healthy weight, blood pressure and cholesterol levels” according to an article written in the WSJ by Safeway CEO Steven Burd in 2009. He claimed that insurance costs almost immediately stabilized after implementation of the program in 2005 and that they were “building a culture of health and fitness.” The idea, of course, is that if people are financially motivated to behave themselves in a way that will reduce their future need for health care utilization, everyone will benefit.The movie showed happy-looking employees jogging around the building.

I got a feeling of unease when I heard this story, although I couldn’t immediately figure out why. What’s wrong with giving people an extra reason to improve their own health? After all, they’re the ones who are benefiting from losing weight, quitting smoking, etc. It took me awhile, and I had to dig into it a little bit, but I think I have an explanation.

Burd’s tone in the article struck me as condescending and infantilizing to the workers, although I’m sure he didn’t see it that way. To me, the subtext was, “if only these fat smokers would just QUIT IT ALREADY, they would save us all a ton of money.” He emphasized that 70% of health care costs are the direct result of behavior. (I wasn’t able to find sources in his article, but it very well may be true.) Regardless, such statements are oversimplifications that grossly devalue the truly transformative experience of changing an unhealthy habit. And it shames and punishes people who are unable to make the changes.

Why is that a problem? If 70% of health care costs truly are the result of unhealthy behaviors, then that must mean those behaviors are probably pretty hard to change. I don’t think that people were totally ok with making themselves ill and just looking for an insurance discount to provide that final incentive to get rid of their pesky congestive heart failure caused by a combo of uncontrolled hypertension, high cholesterol, and diabetes-induced heart attacks.

What seems to be difficult for most super-rich people to grasp is that behaviors aren’t just about an individual’s choices. An individual isn’t isolated from the influences around them, but certainly does suffer from them. Not having a car because you are poor, work a low-paying job with weird hours, take a bus home to a neighborhood where there aren’t any grocery stores, and as a result end up eating crap from the local corner store which contributes to your early-onset diabetes certainly could be considered a “behavior” but I think it’d be more accurate to call it a “complete failure of our unjust society.” Granted, most people’s situations are not that drastic, but it’s an illustration of how even calling something a “behavior” neglects the complexities inherent to real people’s lives.

I’m reminded of a (by all accounts middle-class, relatively privileged) person I met whose weight-loss efforts had stalled recently because of severe depression accompanied by some pretty terrible family and social circumstances through absolutely no fault of their own. Any one of us would have found it difficult to continue losing weight in their shoes, despite this individual being highly motivated. It seems incredibly uncompassionate to just toss that person into the policy. It contributes to the myth that meeting these objective, population-based benchmarks are possible for every person at every time if they’d just work hard enough and take personal responsibility, dammit!  It pits workers against each other – hey, fatty 2 cubicles over! Put down the donut and take a walk around the damn building to get your blood pressure down! I don’t wanna have to pay for your expensive, fancy diabetes drugs!

And perhaps most frustrating of all, it’s based on the premise that absolutely everything, even our own health and well-being, has a price and can be commodified.

I should note that in no way am I attempting to minimize the accomplishments of Safeway employees who actually did make these changes and come out far healthier. I have no doubt that such a program was just what some people needed to provide that extra oomph to get the exercise ball rollin’. But even if that were the case for every employee, isn’t it a bit creepy and invasive that your boss cares so much about your waistline and your cholesterol level?  A “culture of health and fitness” starts to look a little more like a culture of coercion, shame, and anxiety.

And what does this market-based solution do to fundamentally address the inequities in accessing health care? That is, even if every employer had a similar program, what would that mean for people who are unemployed due to say, chronic illness? Would they be further shamed and isolated from society? The program is based, by definition, on employees, so that means the people participating were at least healthy enough to work. Almost certainly this would mean that the care of the very sick would continue to fall in the public domain, decreasing private, corporate health care expenditures, but further increasing publicly funded healthcare (ie., Medicare). Though this type of system, Medicare will continue to be fantastically expensive, making it easier to demonize until we finally move toward a total privatization of health care, dissolution of Medicare and Medicaid entirely, with safety nets only being provided by voluntary, charity care.

Well, it turns out that even though Safeway medical costs did stabilize from 2005-2009, it may not have really been related to the incentive program at all and was heavily weighted towards the early years. That is, costs dropped 12.5% in 2005 when the company drastically changed the benefits it was offering. However, 2009 was the first year that insurance premiums were tied to test results at Safeway. According to David Hilzenrath in the Washington Post, “Even as Burd claimed last year to have held costs flat, Safeway was forecasting that per capita expenses for its employees would rise by 8.5 percent in 2009. According to a survey of 1,700 health plans by the benefits consultant Hewitt Associates, the average increase nationally was 6.1 percent.”  When Safeway Senior Vice President Ken Shachmut was asked why premiums rose so much despite their terrific program, he said “we frankly did not have as much control over things as we should have.”

Maybe they had too much control.

Of note, the idea of financial incentives being not only ineffective in reducing health care costs and improving societal health, but actually impeding these goals is one that I intend to explore in future posts!