Category Archives: Health and Healthcare Policy

Ebola, Secret Serums and Me

An earlier version of this post entitled “Ebola, Monsanto and Me” contained several factual errors. I thank the dedicated readers for pointing them out. Please be sure to use this version for circulation and re-posting.

During the first months of the growing Ebola outbreak in West Africa, other than on NPR it was hard to find any American thoughtful media coverage of this historic public health tragedy. In mid-July I attributed this apathy to several factors: the “otherness” of Africans; a sense that “it couldn’t happen here;” compassion fatigue, especially regarding Africa and Africans; and our own American disinterest in developing and supporting public health infrastructures.  Still today, this kind of “reporting” goes uncritiqued in the mainstream media: “Apparently, the Ebola virus now enveloping three West African nations wouldn’t have developed into an outbreak if not for the people’s ignorance and belief in witchcraft.” I’m hard-put deciding what appalls me most: The not-so-thinly-veiled racism and xenophobia (“people’s ignorance”), the uninformed dismissal of traditional healing practices (“witchcraft”) that effectively treat many illnesses and that are available before and after foreign aid workers swoop in, or the failure to recognize the role of poverty, malnutrition and deforestation in making a region ripe for the spread of disease.

But that’s old news. Ebola has finally grabbed American headlines with two new developments. First, two Americans working in Africa have become infected and – with the help of super-advanced aviation technology – have been flown back to the United States. Second, these two Americans are being treated with a wonder drug “secret serum” that “likely saved” them.

Now we Americans may not care about water purification or sewage treatment systems, but we sure do love secret serums. Hollywood has made millions from that plot line. Indeed, secret serums are such a shoo-in that I’m thinking of writing a blockbuster script about a secret serum that cures poverty (or at least my own poverty!).

But Ebola is no laughing matter. Except, of course, for the pharmaceutical companies poised to profit when the highly touted secret serum goes on the market.

Let me be clear. I am delighted to see that a medication that may cure Ebola is in the pipelines. And I am thrilled to see that the two Americans who received the serum seem to be recovering. But we’d be putting our heads in the sand to think that an untested drug used on two otherwise healthy and well-nourished people who received the highest quality care at every step of the way means much of anything in regard to the realities on the ground in West Africa. We can’t celebrate the great achievement in developing a potential cure for Ebola without considering the legacy that helped Ebola emerge and spread.

Poverty and environmental degradation — all too often the consequences of global economic policies — set the stage for outbreaks of disease. Deforestation with herbicides such as Agent Orange and RoundUp facilitate the spread of disease. Unlike traditional methods of weed control in which farmers and gardeners selectively remove particular plants in order to allow room for the desired crop to thrive, these herbicides typically are spray bombed from airplanes, indiscriminately wiping out plant growth over large areas and often enter the respiratory systems of the people who live in those areas. While the jury is still out, prominent zoologists and virologists hypothesize that emergent infectious diseases such as Ebola may jump from animal to human populations when eco-systems are disrupted, causing new intensities of human – animal contact. According to Nathan D. Wolfe of the Johns Hopkins School of Hygiene and Public Health, “Human activities that occur in lowland tropical forests, such as ecotourism, logging, and the hunting of wild vertebrates have the potential to increase the frequency of microbial emergence.” Coupled with the densely populated living quarters in urban settings that allow for diseases to spread quickly, and malnourished bodies that are less able to fight off infection, the Ebola outbreak seems almost predictable.

I’m not a big believer in conspiracies. I tend to think that just like us good guys, the bad guys are too busy in-fighting to pull off super-duper clandestine hoaxes. And I believe most people who work for even the greediest large corporations rarely intend to hurt others — but their bosses have certainly benefited from it. We need to recognize that the chemicals that made West Africa fertile for the spread of Ebola were highly profitable for the West, and the new miracle drugs to cure Ebola promise to be equally profitable. In these days of giant multi-national corporations it’s virtually impossible to parse out who manufactures what. But from my outsider sociologist perspective what I see is this: Poison the earth with herbicides and when the soil is ruined for everyone else, there’s even more money to be made patenting and selling GMO seeds that can grow in soil no longer suited to traditional agricultural and horticultural techniques. Convince mothers in poor countries to buy infant formula so that mom can come work at their poverty-wage factory, and then sell antibiotics when baby becomes sick because mom can’t afford clean water to mix the formula. Push cigarettes (especially in poor neighborhoods, as R.J. Reynolds does with its Kool brand cigarettes) and acquire Kentucky Bioprocessing to develop post-exposure Ebola serum.

So, on the unlikely chance that my secret serum blockbuster doesn’t work out, here’s another idea. Maybe I’ll start a company that entices people into buying tons and tons of sugary snacks. I’ll have my day-shift workers produce the snacks at factories I’ll build in states where my friendly congressmen and senators have eliminated worker safety regulations and labor unions. Savvy entrepreneur that I am, I’ll have my night-shift workers produce diabetes medication that all of those eaters of my sugary foods will need to take for their rest of their lives. And, just to cover my bases, I’ll require my workers to switch between twelve-hour day and twelve-hour night shifts. That way I can be sure that during any given twenty-four hour period a bunch of them will need pills to be able to sleep or pills to be able to stay awake. With my profits from those pills I think I’ll build a privately owned prison to house all of those criminals caught using illicit uppers or downers. In the crowded prison, tuberculosis and other infectious diseases will easily spread, expanding the market for the antibiotics produced in the factories I’ll open up in countries that don’t have pesky things like minimum wages. Oh – and just to dot my ‘i’s and cross my ‘t’s, I’ll be sure that the prison canteen sells my sugary snacks at twice the price at which they are sold on the open market.

I love it when a plan comes together!

Disabled Rights

This article was first published on Truthout

According to reports from Washington, the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) may come up for a vote in the Senate (again) this week. The last time it came up, two years ago, it did not pass.

On the face of it, the Convention does not seem in conflict with American laws or values. The core principles spelled out in the Convention are respect for the inherent dignity of all persons, the right to individual autonomy including the freedom to make one’s own choices, non-discrimination against persons on the basis of disabilities, full participation and inclusion in society, equality of opportunity, accessibility, respect for the evolving capacities of children with disabilities, and respect for the right of children with disabilities to preserve their identities.

Initially negotiated under President George W. Bush and signed by President Barack Obama in 2009, the Convention has been ratified by 146 countries and is backed by virtually all US disability organizations, veterans’ organizations and women’s organizations. According to supporters, the Convention reaffirms many of the same safeguards already legislated in the Americans With Disabilities Act, including access to education and prohibitions of discrimination in hiring. And while it does not in any way weaken US domestic law or surrender US sovereignty, it provides a clear statement that America has joined with the international community in recognizing the rights of all people regardless of abilities or disabilities.

The most vocal opponent, pressing Republicans to vote nay, has been the Home School Legal Defense Association which maintains that the Convention could undermine the rights of parents, supersede US law and compel government funding of abortions. (There is nothing in the Convention that suggests this would be the case, but “abortion” is always a good buzz word for ginning up opposition to just about anything.).

Our failure to ratify UNCRPD is consistent with US refusal to sign other human rights treaties. For example, the US is one of only three countries not to have signed the Convention on the Rights of the Child. (The other two are South Sudan and Somalia.) We haven’t ratified the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), the world’s primary document on women’s equality. And we haven’t signed The Convention against Enforced Disappearance, which prohibits the secret detention and abduction of people by the state.

Opposition to ratifying all of these treaties follows a fairly consistent line of argument: International treaties infringe on US autonomy and sovereignty, and anyway, “we” don’t need these treaties since we already are “better” than the rest of the world. Regarding the UNCRPD, Will Estrada, HSLDA’s Director of Federal Relations declared, “Our country has been a world leader for people with disabilities. We don’t need to ratify this treaty to do that.”

Disability and Poverty

Mr. Estrada is incorrect. In the United States close to 38% of working age adults with severe disabilities live in poverty; the children of poor parents are substantially more likely than children of non-poor parents to have a physical or mental disability thatlimits their activities and having a child with chronic illnesses or disabilities is associated with greater poverty for parents.

American responses to disability are based on needs rather than on rights; that is, we allocate resources to help individuals on the basis of shifting definitions and thresholds of “neediness” rather than on a stable foundation of inherent rights to goods such as food, housing and healthcare. We also tend to be suspicious of claims of neediness. Services for those who are disabled typically require recipients to spend great amounts of time and energy certifying their eligibility and place a great deal of power in the hands of doctors, courts and bureaucrats to decide whose needs are legitimate. Our safety nets for people too disabled to work – SSDI (Social Security Disability Insurance) and SSI (Supplemental Security Income) – allot average monthly stipends of $1,186.60 and $536.75 respectively. That is not enough to cover the cost of daily necessities of life in most American cities, let alone sufficient for disabled people to live with dignity.

The higher SSDI are provided to individuals who have worked a sufficient number of years for employers who paid into Social Security; SSI is for those who have either been unable to work or whose employers did not pay into Social Security. At this time nearly 8.4 million people receive SSI. More than half of those recipients have been diagnosed with a mental disorder, and the majority of recipients are women (about 55%). These large numbers suggest either that as a nation we are losing our minds and / or that millions of Americans submit to being labeled mentally ill in order to receive the $536.75 per month that allows them access to (minimal) food and shelter in an economic climate that has not been friendly towards the 90% of us who are not born into wealth.

Disability and Punishment

The number of Americans receiving SSI went up at about the same rate as the number of Americans receiving welfare went down in the wake of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (so-called “welfare reform”). Shifting people from welfare to SSI may be seen as a simple bookkeeping ploy, but by labeling certain people or groups as “needy” or “disabled,” we in fact define them as weak, as lacking in the attributes that we as a society admire. Indeed, given the negative qualities associated with need and weakness in American culture, disabled individuals are more likely than other Americans to become targets of correction and punishment.

According to a recent report by the National Center for Special Education Research forty-seven percent of young adults with disabilities report having been stopped by police for other-than-a-traffic violation and twenty-three percent report having been arrested. These rates are twice those for youth in the general population. Young adults with disabilities enter the juvenile correctional system at rates four to five times those of non-disabled youth. An estimated 37 percent of youth in state juvenile corrections facilities are eligible for special education and related services under IDEA, yet 16 percent of youth in short-term youth detention facilities, 52 percent of those in long-term youth corrections facilities, and 71 percent of those in adult corrections facilities were not enrolled in any kind of educational program during their incarceration. And the school to prison pipeline disproportionately picks up disabled youth of color.

Involvement with the juvenile justice system increases one’s probability for involvement with the adult correctional system. With the highest incarceration rate in the world, over seven million Americans are under some form of correctional supervision. Over half of the incarcerated population has a serious mental health issue and 40% suffer from chronic physical illness. Among women the numbers are even bleaker. Of the 47 formerly incarcerated Massachusetts women whom I have come to know over the past six years, 81% live with chronic physical illnesses including asthma, high blood pressure, heart disease, liver disease, Hepatitis B, Hepatitis C, HIV, chronic headaches, chronic pain, arthritis, disk degeneration, cancer and unresolved gynecological problems. Most live with more than one of these health challenges and more than half also have been identified as having learning disabilities. While unhealthy prison conditions coupled with the poor employment prospects facing ex-offenders partly explain the substandard health profile of Americans involved with the correctional system, the fact is that Americans entering prison are already sicker and poorer than other Americans.

Health, Wealth and Moral Worth

Americans are no more mean-spirited than people in the 146 countries that have ratified the United Nations Convention on the Rights of Persons with Disabilities. When I read books or see movies that describe cultures in which disabled people are mocked, teased or even killed, I am thankful for our sense of decency, for the Americans With Disabilities Act, for the accommodations (however deficient they may be) for disabled people. At the same time, however, I can’t help but notice that we are criminalizing disability. And that trend, while particularly dramatic during this age of mass incarceration, is deeply rooted in American culture. Since the time of the Puritans, Americans have identified good health (as well as wealth) with moral worth – with living an estimable life style, with working hard, “taking care of oneself,” doing the “right thing.”  This association between health and moral worth is neither natural nor universal; in many cultures people who struggle with pain, illness or disability are recognized for having greater spiritual gifts, for being closer to or chosen by God or for developing greater sensitivity to the suffering of others. In our culture people living with disabilities are recognized as having greater needs – and we do a great deal to meet those needs. But we have not yet recognized that while needs make one “needy,” rights give pride, autonomy and dignity.

Health Insurance Roulette: The House Always Wins

“As Profits Roll In, Aetna To Expand On Obamacare Exchange In 2015” 

“The Obama administration issued rules to allow for a taxpayer-funded insurer bailout.”

According to Forbes Magazine, health insurance companies have recorded substantial profits in the wake of eight million people signing up for coverage during the first “Obamacare” open enrollment period. That’s great news for stockholders, CEOs, CFOs and a handful of other lucky people. But given that the United States spends more on healthcare while ranking at the bottom of the industrialized world in terms of health outcomes, this isn’t such great news for the rest of us.

The enormous resources that many Republicans have poured into attacking Obamacare have, to my eyes, lulled many of us on the left into forgetting that the Affordable Care Act was no more than a political compromise between middle-of-the-road Democrats and right-of-center Republicans. Though it includes a number of good provisions and a certain expansion of healthcare coverage, the ACA was never designed to overhaul the United States healthcare landscape. We still have a chaotic multitude of financing and delivery mechanisms. We still have for-profit and not-for-profit hospitals, though it’s not always clear which is which. We still use emergency rooms as expensive safety nets that by federal law are only required to assess and stabilize patients (and are allowed to charge a whole lot to do so), not to cure them. We still have a smorgasbord of donut holes, coverage gaps and nonsensical limits on rehabilitative services such as physical therapy. We still have no rational system for allocating services. Moreover, as the Forbes articles cheerfully proclaim, the ACA has been a bonanza for the very same insurance companies that have cherry picked “healthy” members, denied care to sick people, wasted healthcare dollars on astronomical administrative costs, and assessed outcomes in terms of the bottom line rather than in terms of health and well-being. The name Affordable Care Act obscures the reality that even with health insurance, healthcare is hardly affordable for most Americans.

Many of us on the left acquiesced to supporting the ACA because of a vague promise that this would be the first step to real reform, to developing a system of universal coverage in which all people have the right to healthcare. For the past six years I’ve been a good foot soldier for President Obama. I’ve donated money and signed petitions each time the Republicans come up with some new attack on Obamacare. But I want to be very clear: The ACA is not the endgame for progressives. It’s high time for us to stop worrying about the Republicans (who won’t pass any legislation in any case) and push forward a true progressive agenda.

Rights versus Responsibilities

Broadly speaking, there are two basic healthcare paradigms: healthcare as a human right and healthcare as a personal responsibility. Healthcare as a right rests on the deeper belief that all human beings are fragile creatures. Our two-footed upright posture makes us susceptible to injuries and accidents, and complicates the business of pregnancy and childbirth. We have long periods of infancy and childhood in which we cannot take care of ourselves. We live to be old enough for our bodies and (sadly) our minds to break-down over periods of many years. Our social instincts bind us in communities in which infections pass from person to person. Our large brains and nimble fingers develop remedies, manipulations and treatments that allow us to facilitate healing from the injuries and infections to which all humans are vulnerable. Recognizing both the universality and the unpredictability of those vulnerabilities, the rights paradigm valorizes and codifies our moral obligation to ensure that simply by virtue of being human we all have the right to appropriate, affordable, accessible and acceptable healthcare.

In the United States, in contrast, we typically understand both health as well as healthcare to be a personal responsibility rather than a human right. Each individual has a moral responsibility to take care of him or herself by exercising, eating nutritious foods, avoiding stress and going for annual exams such as mammograms (even if these “responsibilities” are impossible for many people to fulfill). Each is responsible for acquiring the resources to be able to afford healthcare which in effect frames healthcare as a privilege for those who can pay. Those unfortunates who can’t afford healthcare bear the responsibility for proving “true” neediness and for following through with requirements for certification and re-certification of that need in accordance with fluctuating policies and to the satisfaction of cadres of bureaucrats. Individuals also have the responsibility to take care of their own young children (this obligation does not extend to other family members or friends, though we do say nice things about people who do care for aging parents). Employers in certain types of companies have a responsibility to subsidize the costs of health insurance for their employees. And, under the ACA, individuals, with certain exceptions, have a responsibility (a.k.a. “individual mandate”) to be insured.

Fancy Gambling

Insurance is, of course, a fancy form of gambling. We purchase car, house, health and life insurance because we want to cover our bases in the event of an unlucky spin of the wheel or tumble of the dice: a fender bender, a lightning strike, a heart attack. We gamble that we’ll get back more than we pay out and the insurance company gambles that they’ll pay out less than they take in. Some people enjoy the adrenaline surge of choosing a number at the roulette wheel or waiting to uncover the next blackjack card. I do not.

When I look at the state and federal exchanges meant to serve those Americans who need health insurance, I feel overwhelmed. I have neither the time nor the knowledge to calculate which plan is the most economical for my particular constellation of medical needs or the needs of my family. The exchanges offer me a variety of packages with varying divisions between upfront premiums, co-pays, co-insurance and deductibles. Should I choose a plan with a high premium but lower out-of-pocket costs down the road? That would be a good choice if I knew in advance that I’d have a lot of health issues down the line and if I had the ready cash to pay the upfront premium. Or should I choose a plan with a lower premium but higher deductibles or co-payments? That would make sense if I knew in advance that I’d have a healthy year – but who among us knows that we will? Actuaries calculate these things on the basis of large populations – not for one individual. Indeed, in calculations I have made based on the Massachusetts exchange (Commonwealth Connector) people are just as likely to “choose” a plan that ends up costing them more than a plan that ends up costing them less.

“Choice” is one of the ACA mantras – that Americans should be able to “choose” the plan that is “right for you.” But that choice is phony. We do not choose our diseases. We rarely choose our doctors or hospitals, and when we do that choice is seldom based on any real data. We almost never know enough about modern medicine to be able to choose our treatments. And alternative and complementary medicine that might constitute real choices (vis-à-vis conventional medicine) is not addressed in the ACA.

In healthcare roulette, putting your dollars down on the wrong number can cost you more than you would ever wish to lose. But like in all games of chance, you cannot know which number is right and which is wrong. Not being blessed with the gift of prophecy, most of us cannot predict what medical needs might arise in the future. Insurance companies, however, hire brilliant mathematicians – trained actuaries – who study massive amounts of data which enable them to calculate how much to charge so that the insurance company takes in more money than it pays out. As they say in Vegas, the house always wins. The Forbes reports make that abundantly clear.

Susan Sered is the co-author of Uninsured in America: Life and Death in the Land of Opportunity.

Ebola and US

I wrote a piece on the Ebola outbreak for Salon.com.

For more, follow this link.

Here is an excerpt:

The United States, according to the CDC, has sent a seven-person team to help in Guinea, and provided protective clothing and equipment for healthcare workers in all three countries. In the grand scheme of things, that is a minimal amount of aid – echoed by the minimal coverage the outbreak has garnered in U.S. media. (Far more attention was afforded GOP Congressman Phil Gingrey’s outlandish and factually implausible comments about refugee children crossing the border bringing Ebola into the United States from Central America.)

There is more than one way to interpret America’s disinterest. One is racism — the sense that the people dying of Ebola are so different from “us” that we really can’t identify with them. Another is compassion fatigue. Isn’t there always some horrible disease afflicting Africa and Africans?

Indeed, many of the Englishlanguage articles that have been written about the Ebola outbreak focus on “ignorant” and “superstitious” Africans who give more credence to witchcraft than to modern medicine.

 

For another post of interest, follow this link:  The Medicalization of the Death and Other Penalties

An Open Letter to Robert McDonald

In response to reports of long-waiting lists, cover-ups and a toxic culture at the Veterans Administration, President Obama nominated Robert McDonald to head the VA. In his public address yesterday, the president praised Mr. McDonald’s long career in corporate America as CEO of Procter and Gamble. In what should be a red flag not only to progressives but to all of the 99%,  House Speaker John Boehner shares the president’s high opinion of McDonald: “Bob McDonald is a good man, a veteran, and a strong leader with decades of experience in the private sector. With those traits, he’s the kind of person who is capable of implementing the kind of dramatic systemic change that is badly needed and long overdue at the VA.” Given that Boehner is on record in favor of privatizing the VA, I can’t help but wonder what sorts of changes McDonald will implement. I also can’t help but wonder why President Obama seems to be falling for the same-old same-old idea that the private sector is better than the public center at just about everything.

McDonald’s nomination is not getting a lot of press. In progressive-leaning news sites it’s been shadowed by the Supreme Court’s Hobby Lobby decision allowing companies the “religious freedom” not to include contraception in insurance plans. But I see these two events as tightly linked — both are part of a growing movement to privilege corporations over people.

The cat’s out of the bag and I assume that McDonald will be a shoe-in to head the VA. But until that is made official we do have a window of opportunity to educate McDonald — who has no experience in health care or social services — about the issues he will face in his new job. To help in that endeavor, I have written an open letter to Robert McDonald. I truly hope he reads it!

 

Dear Robert McDonald,

There’s been a lot of noise lately about the mess at the VA (the mess you are being tapped to clean up), and I’m sure you’ve heard some big name politicians and pundits — including your friend John Boehner — calling for privatization or at least outsourcing of VA healthcare. You are going to hear from lots of people that government can’t do anything right, that the private sector is more efficient and more cost-effective, and that the best thing you can do for veterans is to give them the same choices about their healthcare that other Americans have.

I’m not going to waste your time telling you that the government actually can do a whole lot right. After all, you were a paratrooper so you know that government airplanes and parachutes generally work. I’m sure you have personal experience with well functioning traffic lights, the interstate highway system, safe drinking water and public libraries. And though you have no experience in the healthcare field, you likely know that in the US — where healthcare is structured around corporate models of private ownership, we spend more on health care and have substantially poorer health outcomes than countries with a national health service.

In order to do a good job for veterans you will need to understand why a market approach doesn’t work for healthcare. At Procter and Gamble your mission as CEO was to sell products to consumers who can make informed choices in the free market. But, as I’m sure you learned being a former military man and all, people don’t choose their injuries or illnesses. That makes it silly at best and cruel at worst to tell people to “choose” the health insurance plan that best “meets their needs.” Actuaries can calculate the odds of certain illnesses for population groups, but we mortal humans can’t foresee our own particular future health. Of course, “choice” is marketable in America and even is touted as a selling point for President Obama’s Affordable Care Act. But happily for you and your fellow service and former servicemen and women colleagues, neither the Department of Defense nor the Veterans Administration has ever bought into that idea.

But what about vouchers, you may ask. Even if we agree that all veterans should have the same comprehensive health care coverage, shouldn’t we give veterans the right to choose where they get their care?

Let’s think about that a bit. At Procter and Gamble you could ethically market Charmin’s squeezability over Cottonnelle’s extra-absorbent ripples because you understood that most consumers are capable of evaluating how well their toilet paper does its job. You also understood that in the long run it doesn’t make much of a difference which brand of laundry detergent a consumer uses; Tide may be a bit better or worse than Whisk, but choosing the inferior brand is not going to kill any consumers.

That model doesn’t work in health care. Most people cannot evaluate whether one type of medication, surgical procedure or therapeutic approach works better than another. Nor can most of us assess whether one hospital or healthcare provider has a better track record in dealing with particular health problems or types of individuals. Unlike in the choice of toilet paper or laundry detergent, these differences can be matters of life and death. Let’s take head injuries as an example. Now, someone who doesn’t know much about brains might choose a hospital that looks nice and new and shiny, that has friendly registration clerks, that advertises compassionate patient care. But, trust me, veterans with head injuries would do a lot better at an overcrowded and bedraggled VA hospital where the doctors are specialists in the kinds of injuries suffered in battle and where the cutting-edge research in the world on traumatic brain injuries is being carried out.

At Procter and Gamble you were charged with reducing costs so that you could increase profits for stockholders. And I understand you were good at that! Now, I’m not saying that you shouldn’t streamline VA services so that they will be more efficient. But I am asking you to remember to keep your eye on the only bottom line that really matters in your new job, and that is the health and well-being of our veterans.

I know this job will present many challenges for you, so in closing I’d like to suggest that you bring along with you to the VA one of the mottoes of commerce: The customer is always right. Please, Mr. McDonald, listen to veterans – to men and women, try to understand their concerns, and put their interests above those of politics.

I wish you great success. And please feel free to call on me for advice.

Susan Sered

More on the VA here: The VA Scandal: How About a Reality Check?

Medicalization of the Death and Other Penalties

Executions of three men in Oklahoma and Ohio have been postponed recently in the wake of controversy regarding the botched administration of lethal injections.

Lethal injection table. (Photo: <a href=" https://www.flickr.com/photos/kenpiorkowski/11501354666/in/photolist-iwks3o-7T8bhE-nvjDfh-BFeFH-atNfvj-j1SMiz-dfe8c-57C3i3-5YEDVk-dCh1ad-8ViGsY-8ViGgs-4jjfVB-bwwHQ7-5YJSFo-ediZUT-LtcQL-nuZBTq-nQS5KZ-nvjDjA-nvjDjf-9Q5HY1-apoiVi-nvjDiU-5961SS-cp4c1Q-8VmRzW-drAGpU-ofdXe-4CMpR2-ectFEr-8ViHjY-8ViHdm-8ViHgG-8ViHaq-bo99Lg-8ViGQL-8ViGWJ-7wY18P-8VfCgk-8VfCdH-5nuZnD-7pkB92-4HYrVk-4FNumb-nuq6pB-8PssQT-bM7Gs6-gwXrCE-a2gjpo" target="_blank">Ken Piorkowski / Flickr</a>)Lethal injection table. (Photo: Ken Piorkowski / Flickr)

Capital punishment is by nature controversial. Can the state ever be 100 percent sure that the person sentenced to execution really committed the crime? Is there no possibility that evidence was overlooked or misinterpreted, that confessions were coerced or that there were mitigating circumstances? Looking at the photos of the three Oklahoma and Ohio men raises additional questions: Is it truly coincidental that all three are African-American? Can anyone truly believe that racism did not contribute to their death sentences when we know that African-Americans are incarcerated at nearly six times the rate of white Americans; that African-Americans are 14.2 percent of the total US population, but 34 percent of defendants executed since 1976; that the victims of nearly all lynchings throughout US history have been African-American? And ultimately, from a human rights angle, is it ever morally justified to sentence a person to death?

But the recent controversy is not about these ideological, ethical or sociological issues. The current controversy focuses on a single question: Is death by lethal injection “too painful” and therefore inconsistent with the Eighth Amendment, which prohibits cruel and unusual punishment? That question is, at heart, a medical question.

In our society, doctors function as the primary and often sole legitimate judges of pain. Doctors decide what constitutes “real” pain, who “really” is in pain and how pain should be treated. The monopoly of doctors over the treatment of pain is made clear by the anti-drug laws that have filled our courts and prisons with the many people incarcerated for “illicit” use of the very same medicines that doctors routinely prescribe. With the power to determine who is a drug seeker and who is a “legitimate” pain patient, physicians function as arbiters of the moral order. Of course, a great deal of the hands-on work of treating pain is delegated to nurses, paramedics and pharmacists. But only doctors hold the authority to make formal decisions regarding pain.

This has not always been the case. At other times in history and in other cultures, pain has been the province of shamans and priests, mothers and grandmothers. In other words, pain has been addressed as a moral, spiritual, relational or domestic challenge rather than (or in addition to) a medical one.

The medical monopoly over pain treatment is part of a much broader social process of characterizing problems or conditions in medical terms and adopting medical approaches to address those problems or conditions. This process, known as medicalization, is a hallmark of contemporary Western societies. Over the past century, more and more, phenomena, sensations and experiences have been drawn into the medical sphere. Pregnancy, childbirth, infant feeding, menopause, weight (too much or too little), sex drive (too much or too little), gender identity (think of gender reassignment surgery), anxiety, anger, depression, alcohol and drug dependence – and all sorts of physical “imperfections” from nose to breast size – are handled medically.

In medicalized cultures, physicians are employed to supervise, control and – when possible – correct those who are deemed “deviant.” Invoking an aura of scientific impartiality that other social institutions cannot easily claim, physicians determine eligibility for disability insurance (SSI and SSDI), justify – or not – insanity defenses, and write the prescriptions for the psychiatric medications so heavily used within the penal and welfare systems. While public acceptance of physicians as gatekeepers to social services, pain treatment and other desired goods is premised on the objectivity of science, there are, in fact, significant differences among physicians in how they rule regarding SSI and SSDI, what pain medications they prescribe, and how likely they are to support insanity defenses. Indeed, while we tend to assume that doctors’ first and only loyalty is to their patients, in the current health care reality, doctors generally are paid and employed by insurance companies, hospitals and government agencies (including prisons).

The transformation of capital punishment into a medical event is part of this broad cultural landscape. While the American Medical Association has ruled that physicians should not administer lethal injections, the fact remains that physicians helped design the lethal injection protocol. Lethal injections utilize standard medical materials such as intravenous lines, EKG machines and drugs obtained from pharmacies (barbiturates, pancuronium bromide and potassium chloride). Seventeen death penalty states require physician involvement and all practicing jurisdictions employ medical personnel, though not always doctors. Physicians monitor vital signs, declare death and sign death certificates. And doctors declare incarcerated people sufficiently “competent” for execution.

I want to be clear that only a tiny number of physicians actively participate in administering lethal injections. I also want to be clear that many doctors dedicate their lives to caring for those who are poor, afflicted and underserved. In the current climate of growing alliances between medical and penal institutions, my concerns are structural rather than personal. That does not, however, detract from what I see as a problematic cultural trend of defining and treating “deviance” in medical terms. Los Angeles County – the county with the largest number of incarcerated people in the country – has approved a plan to replace a jail with a correctional center designed to provide care for prisoners suffering from mental illnesses and substance abuse. In New Hampshire, the Department of Corrections is planning a new “gender sensitive” 224-bed prison designed for the particular needs of incarcerated women, most of whom have been identified as suffering from post-traumatic stress disorder as a result of sexual violence. The new prison intends to meet needs for “personal healing”: there is no discussion of the need for freedom or autonomy.

“Treatment” certainly sounds more benevolent than “punishment.” And it certainly is the case that the overwhelming majority of people serving time in US jails and prisons suffer from physical and mental health challenges. Yet the receipt of a psychiatric evaluation reduces a defendant’s chances of having his or her charges dropped. It also increases the likelihood of a conviction, a prison sentence, and a lengthier sentence at that. Given the gross overrepresentation of people of color in US jails and prisons, I worry that the medicalization of the penal system risks adding “insane” to the long list of incurable flaws assigned to black and brown Americans by white America. I worry that rebranding from “offender” to “sick” – instead of seeking new models that get at why people really are caught up in the system – encourages the proliferation of psychiatric medication to be used as chemical restraints (less visible but no less repressive than physical restraints.)

And I worry that utilizing standard medical equipment, procedures, materials and terminology to carry out executions sends the message that capital punishment is, if not therapeutic, at least okay.

Copyright, Truthout.org. Reprinted with permission

http://www.truth-out.org/opinion/item/24251-medicalization-of-the-death-and-other-penalties

The VA Scandal: How About a Reality Check?

The VA Scandal: How About a Reality Check?

Recent reports from VA medical centers about their long waiting lists and subsequent efforts to hide those lists reminded me of a course I used to teach, misleadingly titled, “Introduction to the US Healthcare System.” No, I was not luring in students with the promise of an introductory course and then requiring them to become proficient in advanced statistical methods. The bait and switch was far more subtle: there is no US healthcare system. “System” denotes an overarching set of principles, practices, procedures and organizational structures. I later changed the name of the course to “Introduction to the US Healthcare Landscape” (still a bit deceptive in that one might assume that a landscape is attractively cultivated). A better title would be “Introduction to the US Healthcare Mess.”

Our so-called healthcare system is made up of an incoherent multitude of financing and delivery mechanisms with identities that are far from transparent. We have for-profit and not-for-profit hospitals both of which rely heavily on government funding. We have hospitals owned by religious organizations and hospitals that used to be owned by religious organizations that are now owned by for-profit chains, although they keep their religious names, like St. Elizabeth or St. Jude. We have physician practices that are situated in hospitals and look like they are hospital clinics but are actually just renting space from the hospital. We have insurance companies and hospitals competing for “good” (that is, well-paying and relatively healthy) patients and customers. We have ambulance services that are run by municipalities or counties; private ambulance services run by for-profit companies; volunteer ambulance companies – call an ambulance and you have no idea what kind of bill you’ll be paying or to whom. We have copious amounts of medical records that are rarely transferred from one institution to another, and we have medical errors accounting for an alarming percentage of American deaths. We believe that emergency rooms serve as a safety net, but by federal law emergency rooms are only required to assess and stabilize patients (and are allowed to charge a whole lot to do so), not to cure them. And I haven’t even touched on the anarchy of services for the elderly or the rapidly growing prison healthcare industry.

“System” is not the only misleading word in my old course title. “US” is nearly as deceptive. Health care services, regulations and financing vary enormously from state to state. Each state sets its own threshold for eligibility for Medicaid; in the stingiest states any income at all precludes Medicaid eligibility – essentially forcing individuals to choose between healthcare and food. In other states (such as my home state of Massachusetts) one can earn a fair amount above the federal poverty level and qualify for government-subsidized health care.

The consequences are frightening. Just this morning I spoke with Junie, a fifty-five year old woman whom I’ve known for the past six years. Abused as a child, Junie ran away from home and lived on the streets for many years. In her forties she found out that she was HIV positive. In Massachusetts she received excellent medical attention – the supervised use of retroviral medication kept her numbers well under control and she remained healthy. However, housing in Massachusetts is expensive (the wait list for low income housing can be as long as ten years), and Junie knew she had to get out of the shelters and into a stable apartment in order to stay off drugs and out of trouble. She moved to another state where living costs are lower, and a family friend helped her get into low income housing. However, in that state she was not eligible for medical care. Within a year or so the HIV turned into full blown AIDS with an array of awful symptoms. Her kidneys failing she came back to Massachusetts where she now is sick enough to be eligible for temporary respite housing.

We might be tempted to see Junie as a poor unfortunate who fell through the cracks of a healthcare finance system mostly made up of employment-based health insurance augmented by a safety net for that minority of Americans who are not covered through their employers. That view is simply not correct. In the state of Arizona (the epicenter of the current VA scandal) for instance, the numbers break down like this: 45% of the population is covered by employer insurance (either a the primary insured or as a dependent), 4% have other private insurance, 18% are covered by Medicaid, 13% are covered by Medicare, 2% have other public insurance, and 18% are uninsured. Arizona is among the ten worst states in regard to percent of uninsured residents. The worst states are Texas and Nevada (27% uninsured) and Florida (25% uninsured).

While the full list of VA centers under investigation for fraudulent waiting lists has not been released, the five states that so far are reported to be involved (Texas, Arizona, Colorado, Florida and Mississippi) are all states with bad track records of healthcare coverage overall: tightfisted Medicaid eligibility thresholds and large numbers of uninsured residents.

The VA as the National Safety Net

In much of the country – and especially in the states with high rates of uninsured residents – the VA functions as the de facto safety-net. Approximately one quarter of the nation’s population, about 70 million people, are potentially eligible for VA benefits and services. In any given year approximately 75 percent of all disabled and low-income veterans use the VA system for some service.

I will never forget Yolanda, a school teacher I met in southern Texas a number of years ago. Here is a letter she wrote to me:

In 1998, one of my younger brothers at age 39 took ill. Seizures that he had were mistaken for a heart attack. A CAT scan showed he had a shaded area in his head. “Possibly a blood clot.” said his doctor. It turned out to be a malignant brain tumor rated #5. The worst a person can get. Further testing needed to be done to determine the proper treatment. All of these were very costly and his medical bills had already started to pile. Even then, the doctor said that with the proper treatment and starting immediately with chemotherapy, my brother could live at least 4 more years. We acted quickly to get him on disability and Medicaid. Without Medicaid, my brother could not afford any testing or treatment. None of us siblings were in the position to help out financially. We couldn’t understand the denial of Medicaid since my brother would no longer be able to work. How would he or his wife pay for all his medical needs? The doctor wrote letters for them to present to the Texas Department of Human Resources but they didn’t help in making the decision to approve it. …

Emergency visits to the hospital provided him with supplemental vitamins and potassium, which gave him temporary strength. But his medical bills were rising and the hospital never admitted him for longer time than needed to give him the vitamins and potassium. Usually about 4 to 6 hours. Again my sister in law applied for Medicaid. No luck and my brother still had not received the proper treatment. We started doing fund raising activities to help him with utility bills and other family needs. His wife still angered kept on applying to Medicaid for him.

A friend reminded my brother that he was a veteran of the military service and should check out the VA clinic. My brother and we thought that the VA only helped war veterans and my brother never went to war during his 4 years of service. Mistaken we were. However, to receive medical services, we had to take him to San Antonio where VA Hospitals and more clinics are located. This is a 5-hour drive from our hometown. We took turns driving him to and from every weekend. It was hard for us but harder for him going to and from so many times in his weak state. Eventually he had surgery and was started on radiation. It didn’t help any and a second surgery was done. The second surgery left him paralyzed on the right side. I went from working full time to part time so I could help out more with his physical needs. Months passed and he kept getting worse. My sister in law again went to apply for Medicaid so he could get care locally. It was getting harder and harder to move him on the 5 hour drive to San Antonio. There was no success in getting Medicaid and months passed. The whole situation became hardship for his wife, children and all family members. My brother eventually stopped responding to anything and we were basically just waiting for his time to end. Two weeks before he died at age 41, my sister in law received a phone call to say that finally the Medicaid had been approved. She told them exactly what to do with it. From the day my brother was told he had a brain tumor, he only lived for 1 year and 10 months.”

Yolanda’s brother certainly would have been saved a great deal of suffering if the VA were to have allowed him to receive treatment closer to home. But let’s be clear about this: Yolanda’s brother did not die because of the VA. He did, however, die with more suffering and less dignity because we do not have a healthcare system in the United States.

The Call for Privatization

As soon as the Arizona VA scandal broke, House Speaker John Boehner and others could hardly contain their excitement. This was a golden opportunity for pushing the same old proposal for privatizing the Department of Veterans Affairs. Privatization is not a new idea. But it is a bad one. Who would take over the care of veterans? Halliburton? Corrections Corporation of America? United Health? Aetna? None of these companies have track records that suggest trustworthiness.

There is no doubt that the VA is riddled with problems including half-hearted recognition of the needs of women veterans and a long history of denying that lethal wartime practices such as the use of the defoliating Agent Orange made veterans sick. All of this is inexcusable and the VA must be held accountable. The VA also must be held accountable for hiding the lengths of waiting lists for care instead of screaming from every DC rooftop for adequate funding.

But framing the current unconscionable delays for care at the VA as an issue of government inefficiency is disingenuous. The VA is not responsible for the fiscal conservatism that drives politicians to vote against adequate budgets. (To paraphrase one of my favorite bumper stickers from the 1960s: Things would look a lot different if the VA were to get all the money it needs and the Air Force had to hold a bake sale to buy bombers.) The VA cannot make up for the lack of a national system of healthcare coverage for all Americans, especially when those who serve in the military disproportionately come from and return to communities with few economic resources and little political power.

In the short term (until the VA can hire sufficient numbers of providers) it certainly makes sense to allow veterans on waiting lists to receive treatment at non-VA facilities. In the long term, that is not a good solution. The VA as a national enterprise acknowledges the collective responsibility for our society to care for veterans, recognizes that veterans have unique health needs that are best met by providers with expertise in those needs and provides a level playing field in which all veterans have the right to receive equal treatment regardless of their personal finances or the willingness of private companies to take them on as customers. Permanently outsourcing veterans on the waiting list to non-VA facilities undermines these principles. In addition, the annual Independent Budget published by the nation’s leading veteran organizations reported that the VA is “the most efficient and cost-effective health-care system in the nation.” A 2005 survey from the RAND Corporation [link] similarly found that “VA patients were more likely to receive recommended care” and “received consistently better care across the board, including screening, diagnosis, treatment and follow up.” I recall a conversation with a physician who, splitting his time between the VA and one of the large, prestigious Harvard teaching hospitals, told me that, “At the [Harvard] hospital I need to get referrals and approvals for everything and the patient has to run all over the place to be treated. In the VA it’s more of an old-time G.P. practice – As the doctor I can get the care for my patients that they need all in one place.”

Good News: Embracing Health Care as a Right

Something fabulously exciting has emerged from the public mea culpa of the past two weeks. It turns out that Americans are not afraid to use the word “rights.” Again and again, I’ve heard liberal and conservative pundits say that our veterans have the “right” to healthcare. While national debates over Obamacare have backed away from declaring that access to adequate health care is a basic human right (instead, discussions have been framed in terms of cost and choice), the VA scandal has opened the door for us to think deeply about healthcare as a human right not just for military veterans but for all who serve as teachers, parents, growers of food, cleaners of streets, producers of the clothing we put on our backs, builders of the houses in which we live – that is, for all human beings in that we all, by virtue of being human, are depended upon and depend upon others for our very survival. To my mind, the real lesson we need to learn from the current scandal is quite the opposite of privatization which would further chop up and distribute responsibilities (and profits) for healthcare among more and more corporations. What we need to learn from this scandal is that the VA should become part of an integrated, rational, coherent national healthcare system.

For more on the VA follow these links: On Memorial Day: “Remember the Ladies” and An Open Letter to Robert McDonald