End of Century Musings
Malaysia is being pushed to modernize and this is attracting multinational companies and putting pressure of their healthcare system. The country's extensive public healthcare system can no longer provide free care on demand, promoting an expansion to the private sector. Rationing is common at the nation's approximately 110 public hospitals, and doctors and other healthcare professionals have fled the public system for better paying private-sector jobs. Two U.S. players, Aetna U.S. Healthcare and United Health Group recently entered the market. Britain's largest insurance companies are expected to follow suit. Overall, 30 or more managed-care organizations have registered with the Ministry of Health to do business in the country, according to officials. Howard Kahn, vice president of global health business at Hartford, Conn. based Aetna International, says he expects the plan to grow "by leaps and bounds." Just four years after their 1995 introduction into Malaysia, managed care organizations have enrolled approximately 600,000 people.
Predictably, physicians are not happy about the entry of managed care. "Right now, the doctors are trying to stop real U.S.-style managed care from coming in," says Pang Hsiang Chye, A Malaysian-born healthcare consultant at Milliman & Robertson in San Francisco, who predicts that some managed care companies will fail to deliver promised services or pay providers. Sounds familiar.
On December 17,1999 Drs David Jaffe and Wayne Spiggle organized a burning of their HMO-related paraphernalia. Dr. Jaffe is a dermatologist practicing in Havre de Grace, Maryland. I spoke with him on Thursday, December 16th. He told me that he has been with HMO's for six years and over this time their style and ways of doing business has changed. Medications are routinely questioned, as are modes of therapy. Dr. Jaffe is a specialist and he is leaving managed care due to bureaucratic failure to provide "timely and accurate referrals. Sometimes the patient's care is compromised by referrals that require doctors to evaluate but do not treat!" He also said that there were "computer breakdowns constantly that further compromised care. This also affected the quality of care as the number crunchers made bigger profits by holding down care." This demonstration was the kick off to Rescue Health Day this coming April 1, 2000. More on this later.
I have researched the work of a lot of geriatricians. They have come to believe that modern medicine does not work well for old people. Old patients serve as a mirror, reflecting the limitations and sometimes the absurdities of modern medicine. The Nazi Holocaust began with just a simple and subtle "shift in attitude" that accepted a philosophy of government that judged people based upon their perceived costs and benefits to the state. The first manifestation of this was the open discussion during the time of the Weimar republic, prior to Hitler's takeover of Germany, of government schemes for the sterilization and euthanasia of people with severe psychiatric illnesses. By 1936, medical extermination was widely and openly practiced, and the category of those deemed a burden to the state, therefore socially unfit to live, had expanded to encompass all people with chronic illness. It's not a giant step in thinking to the post I received from a research analyst at "Not Dead Yet." He works in disability rights advocacy. His point is that "much of what is often mistakenly called 'end of life' issues are at heart disability rights. When medical people talk about 'quality of life' they are usually talking about disability issues. As a result, a lot of us with disabilities get treated in the medical arena as though we were in fact close to death". Doctors are rethinking and being pressured to jump to the conclusions that disabled people want Do Not Resuscitate orders. Medical professionals tend to have a "significantly more negative attitude about disability than the individuals themselves have. This is true in all phases of life. Many parents of children with disabilities tell stories of medical professionals urging them to 'let nature take its course' in relation to their newborns with conditions such as spinal bifida or Down syndrome." The kindest spin one can put on this is that these doctors are projecting, that is, they wouldn't want to live with severe disabilities and assume (incorrectly) that others feel the same way. This is not empathy, but feels like it to the person projecting.
Last month's ABC Town Meeting with Gore and Bradley was devoted almost 60% to the subject of healthcare. Just a year ago everyone told me that I was crazy and people didn't want to hear "depressing" things like that. Well, it has become the #1 campaign topic, at least for now. We must allocate more money, rethink our present model for healthcare, embrace a new mindset for providing to the old and very old.
Dr. Leo Alexander, a prominent American psychiatrist was the chief U.S. medical consultant at the Nuremberg War Crimes Trials. One question perplexed him: Why was the German medical profession unable to effectively resist the Nazis? He could not find any documentation, and was forced by the facts to change the focus of his research to an examination of the process by which the German medical profession came under the total domination of Hitler's government. He discovered that that the Nazi Holocaust began with "a subtle shift in attitude that accepted a philosophy of government that judged people based upon their perceived costs and benefits to the state." You can see where this will take one especially in our culture of youth, arbitrary standards for beauty, money, power, etc.It all can start from small beginnings and with the acceptance of the "progressive" and "rational" idea that some people had "a life not worthy to be lived" and were a burden to society and to the state. Once we remove money from the equation, as well as shareholder profits, the bottom line, compensation packages for CEO's - the whole ball of wax in other words, and see healthcare as a basic right, not a gift for those who happen to be unproductive, chronically ill, or just down on their luck, we will be well on our way towards a humanitarian healthcare system. Why do I contrast the Nazi regime with our current US system? I am trying to show that there is a dangerous slippery slope mentality that creeps in little by little, very insidiously, almost without notice, because we put so much value on youth, on the exterior appearance. People over 50 are constantly reminded in subtle and overt ways that they have limited time and are no longer valuable to society. There are different treatment options for the young and the old and worse for the very old. The New England Journal of Medicine December 30,1999 published a special article entitled "Underrepresentation of Patients 65 years of Age or Older in Cancer - Treatment Trials". It determined that "studies have documented the under representation of women and blacks in clinical trials, and their recruitment is now federally mandated." However, it also noted that "little is known about the level of participation of elderly patients. We determined the rates of enrollment of patients 65 years of age or older in trials of treatment for cancer" and found that "there is substantial under representation of patients 65 years of age or older. The treatment should be clarified and policies adopted to correct this under representation."
I have often wondered why Mother Teresa was criticized at all. She actually devoted her life to the sick, interacting with them on a daily basis. It is very easy to judge , far more difficult to soothe people and train others to do the same thing. The question of religious zeal should not enter the equation--it is a cheap shot.