Philip Alcabes discusses myths of health, disease and risk.

The Agony of the A.M.A.

Sam Stein at Huffington Post comments on the American Medical Association’s latest attempt to (as he puts it) torpedo health care reform by opposing any government-sponsored insurance plan.  The AMA’s announcement was reported Wednesday night in the NY Times.

At DailyKos, doctoraaron explains why he is resigning from the AMA, and is participating in Physicians for a National Health Program.  And DemFromCT notes the high public support for reform, provided it’s affordable.

The AMA is already catching flak for sounding like, well, a bunch of doctors interested only in preserving physicians’ privilege.  Of course, that’s what the AMA is – it’s a trade guild, and (it thinks) it’s doing its job.  The only surprise – especially given how many physicians are firmly behind reform of health care financing — is that the organization is so willing to be so open about being so neanderthal.

The AMA’s statement sounds to us like the organization’s dying gasp.  It’s standing up for a vanishing version of what it means to be a doctor.

In fact, the history of the AMA’s own stance toward social insurance is revealing.  In The Social Transformation of American Medicine, Paul Starr explains that until the 1930s the AMA didn’t like the idea of any medical insurance at all — it was fearful that physicians would fall under the sway of the public health establishment if social insurance were instituted and under the control of insurance companies in the case of private insurance. The AMA has always been more worried about doctors losing control over their own practice than about financing.  Patient care isn’t the AMA’s job, and never has been.

Why social health insurance failed in the U.S. is a complicated story.  It involves ideology, of course, but it’s inflected with plenty of nuance:  the troubled relation of labor unions to American industry, the not-so-troubled relation of industrial corporations to the American political establishment, political favor currying, the rise of scientific medicine, the entire question of whether there should be insurance for medical care.  Through it all runs the AMA’s devotion to the image of the physician as independent decision maker.

The reason for the AMA’s death agony today is that it’s defending a dying species.  Physicians don’t get to make independent decisions much.  And the backward-looking AMA isn’t showing any interest in forward thinking about the positive roles that doctors could play in a really care-centered set-up.

The business of doctoring, which was once a trade that pitted physicians against herbalists, apothecaries, surgeons, patent-medicine hawkers, faith healers, etc., competing for access to Americans’ bodies, has become just a trade, once again. Only now, it’s not that physicians are competing with snake-oil salesmen — it’s that the business of caring for Americans’ health is no longer managed by a medical professional working one-on-one with a patient.

That individual suffering isn’t the main focus of the big, costly healthcare system is well known to anyone who has sought diagnosis of a troubling condition or relief from chronic problems.  That physicians are themselves just cogs in the system isn’t so obvious — until you listen to them talk about their own frustrations.  They wish their practice could be driven by patients’ needs or, at least, by evidence on what treatments work best.  But often the control is exerted by the institution, and by insurance companies’ policies on pricing and payout.

The AMA is still fighting for the vanishing breed, though.  Someday soon, the AMA will have to disband because its constituency, the exalted independent physician, will have become extinct and the organization will have failed to recognize just what the rest of America — including most physicians — wants.  Meanwhile, don’t be surprised to hear its dying gasps.

ADDENDUM:

Just saw Abraham Verghese’s “To the AMA:  It’s Not About You” post at Atlantic magazine today.   He urges the organization, “please don’t tell the American public (a public already disenchanted with physicians and health care) that you are doing this for their benefit because of your great concern for the patient. The public does not believe you. They aren’t that naive.”

By Philip Alcabes | June 12th, 2009 | Categories: Health Professions, News, Physicians, public health | Tags: , , , , | 1 comment

It isn’t health if it isn’t for everyone

A couple of weeks ago we toured the Wildlife Health Center at the Bronx Zoo with Dr. William Karesh, director of the field veterinary program for the Wildlife Conservation Society and VP for WCS’s Global Health Program.

We learned that veterinarians from the Wildlife Health Center do rounds for all animals in NYC’s zoos and aquarium; animals needing special care are brought to the center.  Health records for all animals in zoos are electronic and are maintained with common software – making it straightforward for health records to be transferred whenever the animal is transferred from zoo to zoo, anywhere in the world, and of course facilitating research.

Animal health seems far removed from human health – not only in that it’s much harder for caregivers to see any person’s prior health records than it is for vets to see an animal’s.  We think of wildlife health as distinct from our own.  Even when an event like the 2001 foot-and-mouth disease outbreak in Britain causes us economic distress and affords people the ghastly sight of piles of cow carcasses piled up in farm fields, we don’t see the connections easily.

Increasingly, it’s becoming apparent that the health of human populations depends on equilibria in the wider world.  We have our military-style campaigns to defend Fortress Humanity from microbial invaders:  we use antibiotics, vaccination, and close monitoring of routes of ingress via food and water.  They work, at least up to a point.  But the evidence of MRSA, antibiotic-resistant TB, avian flu, S. Saintpaul in jalapeño peppers, and the new swine flu is that those measures aren’t perfect.  There’s not going to be any Conquest of Contagion (as Charles E.-A. Winslow put it in 1943),  and so-called victories such as the use of immunization to eradicate smallpox and control polio won’t be repeatable for every germ.

In the long run, as the One World, One Health movement suggests, we’ll have to shift to a much broader view of the planet as a system – in which we humans are co-resident with other species.  We might manage to ward off a serious flu outbreak with vaccine (the jury’s still out on whether the current swine flu strain can become highly damaging or not, but it’s reasonable to think that some flu strain might).  And we should improve food-safety systems to guard against outbreaks of salmonellosis and the like.  But we have to move toward a more complex understanding of how human health, animal health, environmental conditions, and international transfers of food, animals, goods, and people interact, especially with respect to the movements of microbes.

In that regard, it’s  troubling to learn from DemFromCT’s post at DailyKos yesterday that Sen. Max Baucus says that a new healthcare plan in the U.S. will not cover undocumented immigrants. It’s cruel, of course, to deny care to immigrants.  But it’s also shortsighted.

If we continue to have a huge, frequently mobile proletariat of migrant workers  forced by economic duress to travel from country to country in search of a living wage and we also make it impossible for them to get care, we’re harming ourselves.  Even those who aren’t moved by the humanitarian aim of ensuring all individuals a decent life should be moved by self-interest.  Creating a means by which disease and disability can move around with the people who suffer from them will undermine whatever arrangements we make for health.

One Health means we have to think about the interactions of many species – and it’s ridiculous to exclude some members of our own.

By Philip Alcabes | May 23rd, 2009 | Categories: Disease, News, public health | Tags: , , , , , , , , , , | Comments Off