Friday, July 31, 2009

Swine Flu Requires Serious Medicine--and Serious IT

Reporters, as well as supporters and critics, have all noted that Barack Obama has started describing his proposal as "health insurance reform." Which is to say, Obama, under pressure from Blue Dog skeptics in his own party, is now striving to make his once-bold plan seem more and more economical and thus presumably less threatening to moderates. Of course, in euphemizing his language, he risks euthanizing his proposal--he is making his plan seem, frankly, boring--can anyone be expected to go to the barricades on behalf of "health insurance reform"? (Now, of course, some argue that "health insurance reform" is just a rhetorical figleaf for "single payer," and that should keep some people awake, but SMS suspects that the snooze factor of "health insurance reform" will overcome the stealth-cleverness factor.

But in the meantime, there big doings in the realm of Serious Medicine. An article in Forbes tipped SMS off to the existence of a cool website dedicated to tracking Swine Flu (see map above). The work of Dr. Henry Niman, helped along by Rhiza Labs and Google, is a reminder that while politicians in Washington are wrestling over "health insurance reform," medical scientists--now joined by IT experts--are wrestling with matters of life and death. If reports that as much as 40% of the US population could catch swine flu, well, that's a reminder that when we get through horsing around with "health insurance reform," the real work of Serious Medicine will still be waiting to be continued.

Health insurance reform, and health care policy in general, are certainly important. And it's worth exploring ways to rationalize coverage, get everyone covered, eliminate price-gouging and so on. But it's more important that Serious Medicine go forward.

Thursday, July 30, 2009

Politico's "Arena" Section Asks About Obamacare

"Why is Obama losing the battle for public opinion on health care? Can he turn it around and, if so, how?" That's the question posed by Fred Barbash, editor of the "Arena" section of Politico.

And here's what I contributed:

Obamacare is in trouble for the same reason that Hillarycare ran into trouble--because people in Washington DC repeatedly and relentlessly mistake “health care policy” for actual health.

To most Americans, health is just that--the sum total of their medicine, their diet and exercise, and their general well-being. To these ordinary folks, “health care policy” is abstract and intimidating at best, scary and sci-fi-y at worst.

But Washingtonians thrive on “health care policy”; they revel in the complexities and ideologies that are so off-putting to most Americans. Perpetually funded by the government, corporations, and various non-profits, Washington wonks never seem to notice that the public isn’t with them--until it’s too late.

If people here want to regain the confidence of people beyond the Beltway, a new strategy is needed--a Serious Medicine Strategy. That would be popular everywhere.

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.

Saturday, July 25, 2009

Rabbi Michael Lerner Criticizes Obamacare, Confronts Serious Medicine--The Issue is Tangibility

"Why Can't Obama Convince the Dems?"--that's the pointed question about Obamacare posed by Rabbi Michael Lerner, for Tikkun. Lerner is an old-line leftist, albeit with a thoughtful spiritual bent. And so his answer to Obama is to couch a leftward lurch toward a single-payer plan in heal-the-world communitarian language. Advises Lerner: "Obama should rename 'single payer' the 'solidarity and caring for-each-other health care plan.'"

OK, we'll see how that prescription goes over. Obamacare was in trouble, even before the presidential detour into racially charged politics, for the simple reason that under Article I of the Constitution, Congress has more power than the Executive Branch; and so if Obama can't convince Democratic senators, such as Max Baucus, Kent Conrad, and Mary Landrieu to sign on to "single payer," well, that's that.

As noted in yesterday's posts about Mary Berry and Daily Kos, the problem with the soft liberalism of Obamacare is that it doesn't seem compelling to ordinary people--unless, of course, they read the fine print --in which case, they get scared. By contrast, the lefty single payer advocates, such as Lerner, do get genuinely excited over a Euro-style health care plan. Their problem is that they are in the minority.

The challenge that "health care" experts face is tangibilization--can you feel it? Can you taste it? Obama people could feel it and taste it during the 2007-8 campaigns against Hillary Clinton and John McCain, but not enough of 'em get worked up over Obamacare. And unfortunately for Lerner & Co., most people, vaguely in the middle, don't get worked up over an American NHS.

Indeed, ordinary people have a different set of preferences. For most folks, "medicine" is about getting results: you get sick, you go to the doctor, and you get better. (And on the doctor/caregiver side, the same thing: the patient comes to you, and you help him or her.)

And for many people, "health" has the same bottom-line orientation: You take care of yourself, eat right, exercise, etc., and you are healthier as a result. In both situations, medicine and health, there's a simple (or at least presumed) cause-and-effect.

But in the case of "health care," a curious kind of abstraction settles in. The government is neither the care-receiver nor the care-giver. Instead, the state is an intermediary, a financier--and maybe a ration-er. That's a scary prospect to many, and at best an uninspiring concept to many more.

What is popular is government-funded medical research--just about everyone thinks that that is a good idea. Such research is popular because it's tangible: It has the benefit of human interest, and quite possibly intense personal interest--for those who have the condition being researched, or know someone who has it, or think that they might get it. (As we can see, the constituency for medical research quickly hits nearly 100 percent of the population.)

If Obama had been talking about curing cancer, or curing Alzheimer's, he would be winning, not losing. Again, the issue is tangibility. As an aside, Education Secretary Arne Duncan shows that he has a sure grasp of this tangibility concept. He has an op-ed in The Washington Post this morning under this headline "Education Reform's Moon Shot." The "moon shot" analogy, of course, hearkens back to one of the greatest successes of Big Government operating in tandem with Big Science: the Apollo program, which took Americans to the moon in 1969, just seven years after John F. Kennedy promised that we would do just that. A promise to put a man on the moon is, above all else, tangible. And that's the point: If it's tangible, and if it's backed up with credibility, people might decide that they like the idea. By contrast, people rarely feel affection or warmth for intangibles. There's no guarantee that Duncan will succeed--plenty have failed before him--of course, in which case, he might some day regret ever having made the promise in the first place. But at least for now, we can admire Duncan's ambition, and hope that he succeeds, for the sake of all of us.

In the meantime, speaking of Serious Medicine, I see on the Tikkun site that Rabbi Lerner has been suffering from cancer. My best to him, of course, but a look at his personal health-related diary-blog shows an extraordinary attention to medical detail. Lerner could write a book about his cancer and treatment--maybe he will. And such a book would certainly be be interesting to a larger audience, because it's a real life story; all of us could think, "There but for the grace of God go I."

That's the point about Serious Medicine; it's about real life. Here's Lerner's latest entry:

The CT scan at UCSF of my lung shows that the cancer has been removed and whatever remains at a microscopic level has not yet returned in full force and may never do so! So, each six months I'll have a follow up scan, but right now, I'm as Debora puts it "squeaky clean." Ditto, the removal of the pre-cancerous tumor in my duodenum has been completed successfully and no further treatment is needed inthe foreseeable future except regular endoscopies and colonoscopies. Ditto, the anemia has been dramatically reduced!

The only sore spot, so to speak, is the enlarged prostate and PSA of 5.2, which my urologist is treating with the anti-biotic Cipro at the moment, but, if it stays way above the normal "1" level, will requirea biopsy sometime after September.

Again, we wish Rabbi Lerner a full recovery and the best of health, even as we note the Serious Medicine--not a shuffle in health care financing, and certainly not rationing--that it will take to make him well and keep him well.

He's worth it, and so are the rest of us.

Serious Medicine Strategy Takes Over From Serious Medicine

See earlier posts, please see