Wednesday, July 29, 2009

The Shulmans: The Cost of Serious Medicine vs. The Cost of Dying Young

Julius Shulman, the famous architecture photographer, died on July 15 in Los Angeles, aged 98. That’s old. His father, by contrast, died young--and, as we shall see, that’s expensive.

The 1960 photo above, taken in the Hollywood Hills, is one of Shulman’s. As The Associated Press observed in his obituary,“It was a lifestyle statement that made Shulman's career.” Indeed. That shot of a “typical” Hollywood Night set a tone of desirable LA glamor that endures to this day.

The mere fact that The Washington Post, on the opposite coast, chose to run the AP’s lengthy obit, under the headline, “Most important architectural photographer,” testifies that Shulman was a remarkable man in many ways; not only did he live to be nearly 100, but he kept artistically active almost to the end of his life. As the AP’s Sue Manning reported, after selling his photo collection to the Getty Museum, “Shulman then teamed up with collaborator Juergen Nogai and worked into his 90s to build another library of photos.” So obviously Shulman lived a strong and vigorous life, thanks to whatever good combination of heredity, lifestyle, and health care that he enjoyed.

And yet there's something else that’s of particular interest to students of Serious Medicine: His father died at a young age. Of what? Of tuberculosis, a disease that back then could strike anyone down. As the obit notes:

“When he was 10, his family moved to Los Angeles and opened a dry-goods store. His father died of tuberculosis in 1923, leaving his mother with five children and the business.”

That was the way things were in those pre-antibiotic days. Dr. Lewis Thomas, author of the classic 1974 work, The Lives of a Cell, described the health status quo of the 1930s, when he started out as a medical student:

“The major threats to human life were tuberculosis, tetanus, syphilis, rheumatic fever, pneumonia, meningitis, polio, and septicemia of all sorts. These things worried us then the way that cancer, heart disease and stroke worry us today. The big problems of the 1930s and 1940s have literally vanished.”

All those infectious diseases, all those big killers. Vanished. And how did they vanish? Serious Medicine is the answer. Starting in 1943, Streptomycin began the conquest of tuberculosis--the co-discoverer of Streptomycin, Selman Waksman, won a much-deserved Nobel Prize for Medicine in 1952. TB might have “literally vanished” when Thomas was writing in the mid 70s, but as we know, there are no final victories in anything. And so today, thanks to sloppy public health practices--not to mention the ineluctable power of evolution--TB is a killer once again. So let’s hope that someone is still practicing Serious Medicine against the renewed threat of another TB epidemic.

And from a Serious Medicine Strategy perspective, let’s understand that the death of Julius Shulman’s father, at a relatively young age back in 1923, was not only a personal tragedy, but also a financial loss to his family and to all Americans. We'll never know how long the elder Shulman would have lived if streptomycin had existed when he needed it, or what he would have done with his life, but we can use actuarial data and statistics to reach at least an informed estimate. It surely would have been a big number--and so, from the coldest possible perspective, it would have been worthwhile for the rest of us to help keep him around.

Yet while the cost of dying young is a debit to a nation, the cost of dying young is never debited to the specific account of the nation’s health-care system. Indeed, from the narrow perspective of The System, early death saves money for the government; the elder Shulman did not live long enough to collect Medicare. Health-care experts can easily calculate how much treatment costs, but they can’t--or won’t--calculate the cost of incapacitation to the commonweal.

If you go to the hospital, Peter Orszag, chief bean-counter in the federal government, knows how much that costs. And such a hospital visit bothers him, because he thinks we should spend less (and get less) on health care. But if you die young, well, that's someone else's department. Someone else's loss. Obviously, we need a better system of accounting for social goods and bads--another task for Serious Medicine Strategists.

In the passing of Julius Shulman’s father, it was the Shulman family’s immediate loss, back in the 20s. But the bell tolled for all of us.

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