Sunday, January 16, 2011

Health care: right or privilege?

Our society is pretty thick with buffers in providing food, housing and disaster relief. Most of us think human beings should be treated like we would want to be treated, and that it is inhumane not to do the best we can to help alleviate suffering. There are a lot of ways the delivery of heath care could be seen as a public utility, and legislation could focus on the way we use health care, the regulation of profits, the payment for health care coverage (not really insurance, because it is needed as a maintenance of health also) in either tax incentives or benefits for individuals and families, and so on.
So the whole thing becomes the big ball of wax and tangled gordion knot that we know it to be. Some system-makers, and people who want to have everything be "fair and the same for all" remind me of naive parents who think they will be able to treat their children EXACTLY the same. In reality, the more we stick protocols to each disease, and force the "providers" to follow them, the stiffer and meaner the Bureaucracy with a big B will become. And what will happen is the same thing that occurs in any system --- there will be some outliers, some non-responders, some bewildering failures, and more nit-picking to cover these scenarios.
We weren't able to take the profits out of the insurance industry by capping what their profits should be, like a true public utility. We have also not been able to curb the profits of the pharmaceutical corporations, and the patent laws and US protectionism are being used against us and our patients. Physicians are not a strong-enough lobby to be able to get ourselves paid better, and ultimately, the "extenders" will be how they stretch the dollars.
We are probably on a long trajectory of shifting pollicies, as we go forward. And some people will keep arguing about rights and needs and obligations, in order to try to get more patients better care in a systemically coherent way.
One of my favorite stories is in the book "Mountains beyond Mountains" about Dr. Paul Farmer and his work with Partners in Health. Dr. Jim Kim has that brilliant kind of mind of a systems-oriented thinker. And he looked at the TB-DOTS program, and tinkered with what it would take to really fix it-- and he was able, by a few international miracles, to get some new pharmaceutical companies to come forward and make the drugs cheaper, so more poor patients with multi-drug-resistant TB could be effectively treated.
That is the kind of paradigm shift we need now. We need IUDs to not cost $800 apiece. We need oral contraceptives to be "affordable" to poor women on Medicaid. We need seniors to get preventive care so they won't come in with super-advanced problems which are harder to effectively treat. But we also know that keeping people healthy costs more than letting them suffer and die. And so we face these intrinsic limits all the time about what is actually "reasonable" or "the standard of care"-- or something EVERYONE should have ( which is how I think a lot of unreflective people would define a "right"). There are practical details which can easily be helped, and others which are extremely difficult to change. But change is inexorable, and we really can't stay the same. We already see it in the push for palliative care, and more Hospice care. There is a struggle, and people fall on different parts of the spectrum, but more are starting to be adamant about not wasting precious medical resources at end-of-life. The shift is in the whole society, not just the medical "providers". Business people are weighing in, as well as the ethicists. Things are getting curioser and curioser!

Saturday, January 15, 2011

more on mental illness and societal support

There have been gains in mental health care in the past 50 years. Some medications have made it possible for previously hospitalized patients to live in the regular world and even hold jobs. But some care is often still needed, and these ...patients often have poor insight and poor skills for managing their own illness, and their own lives. Often, they would do best in an assisted-living facility, with someone acting like a house-mother, watching to be sure they eat, drink enough fluids so they don't get dehydrated, take their medicines, and see their doctors regularly. When they start to get sicker, and withdraw, this house-mother is invaluable in alerting the medical team, to be able to step up the care.
People who really want to understand more are urged to go to the NAMI website for advocacy for the mentally ill. Also, I recommend the book, "Surviving Schizophrenia" for families and advocates of patients, by Dr. Torrey. We simply MUST try to make it safer for mentally ill patients to live in our world. It is dangerous and complicated, and they need and deserve our help.

Mental illness, Parents, and Support of Society

I think that many parents struggle to help with their children with mental illnesses as long as the parents are alive. But the fact is, it becomes harder to control their behavior-- harder to get them to take their medicine, harder to make... them get up in the morning, or do the dishes, or go to the doctor. Some parents have been terribly hurt by out-of-control rage attacks by mentally ill almost-grown or adult children. Schizophrenics sometimes hear voices which are terrible and compelling, screaming at them to kill or hurt people they would normally love. We cannot pretend this is easy. I am a gynecologist. I have had mothers with mentally ill daughters come to me in tears, as they strive to help meet the family planning needs of their daughters. These moms know that if she gets pregnant, the primary caregivers for their grandchildren will be themselves-- older and more tired than they already are. Mental health services are also very hard to come by, and no insurance company wants to give this care to grown children, without prohibitive policy fees. Many mental illnesses are waxing and waning in nature, and sometimes the patient needs hospitalization, which is extremely expensive. In Arizona, there is almost no medical care for the uninsured, poor, unemployed mentally ill. In some schools, the school is required to help until the student turns 18-- then they are on their own. Why are these patients living under bridges, and alongside highways, where rape and murder happens so easily? Because we don't want to abridge their freedom! In California, Ronald Reagan emptied the mental hospitals, so that these poor patients could enjoy this freedom-- but no follow-up clinics got set up to help them when they failed to be able to care for themselves! This is blind and stupid, to not look at their need for safety, their fragility and their vulnerability to the terrible curse of mental illness. Their poor parents-- being told to "keep on, keeping on," because society does not want to help shoulder the burden for their care!