This Noble Land (18 page)

A man on dialysis asked me: ‘Suppose Milliman or Congress decides to cut the number of dialysis machines by two thirds. Will the congressmen who vote for such an action agree to serve on their hometown triage committees: “
You
can have one of the chairs. Unfortunately
you
can’t, so you must die”? I doubt it. Hard facts would supersede Milliman cost cutting.’

Fortunately, there are not many diseases like total kidney failure, so Milliman procedures have a possibility of reducing our national medical bills by an almost unbelievable amount, and I expect them to be adopted throughout the nation. At one time I was inclined toward recommending that HMOs expand their coverage in America, and for a while I thought I might join one. But when I announced this publicly I was greeted with loud protest and a recitation of several dozen horror stories. In fairness I must share a sampling.

The thoughtful doctor:
When this doctor heard me speak favorably of HMOs he grew choleric: ‘They’re making robots of us doctors. Medical decisions of the gravest kind are being imposed by secretaries on the telephone. I had a woman patient with a severe complication that only an on-site examination and diagnosis could treat. I explained this, but the secretary with no medical training whatever told me: “Rules are, Doctor, that she gets one
day in the hospital, and that’s it.” If I wanted to keep her for two more days, I could do it at my own expense or hers.’

The highly trained specialist in an exotic field:
‘I’m embarrassed to say this, but there are not many of us in all America who are expert in this area of medicine. But when I advocated a somewhat unusual treatment for a patient with an advanced case, the girl on the telephone said: “Doctor, you know that’s not authorized. Insurance does not cover that and your appeal is rejected.” I was powerless, and I’m the expert with years of training, overruled by a telephone operator.’

A typical patient.
‘I’ve paid my entry fee and been on the rolls for seven months and have not yet been able to schedule a meeting with my primary health care provider. I have a feeling we’re being treated like cattle.’

A typical family physician of superb reputation:
‘I’ve been forbidden to recommend to any of my patients that they consult with a specialist in some field in which I’m adequate but not really well informed. To save pennies they invite serious setbacks that will cost thousands.’

Because of this constant drumbeat of criticism, I have become wary of placing too much power in the incestuous relationship of insurance companies and HMOs as a solution to our medical problems. Are the Milliman rules turning doctors into robots? Or are the protests of the doctors merely self-serving laments for the simpler—and more profitable—doctor—patient relationship of yesteryear? Are those days not doomed by the computer, which can handle diagnosis so ably, and by the Milliman rules, which show the health care profession how to save money? After painful attention to what is best for the country, I must vote against the HMOs as dictatorial, self-aggrandizing and indifferent to the welfare of the patient. Their abuse of doctors disqualifies them, and I see them now as a clever mask to perpetuate
the tyranny of the insurance companies. The persuasive grain of truth in the otherwise absurd Harry and Louise advertising blitz was that we
do
fear having the medical decisions, so crucial to our very lives, being made by HMO secretaries and telephone operators rather than by doctors. There must be a better way.

But just as I am awakening to the dangers of the HMOs I learn that Congress is thinking seriously of using them as the basis of our national health care system. They and the insurance companies will dictate to patients, doctors and nurses how they shall operate. Saving money will become the rule in American health. I must protest against this unwise and brutal decision. The insurance companies’ profit margins cannot be the driving force behind what is and what is not adequate medical care, and neither should the profit margins of organizations such as the HMOs be the decisive factor. The motive for our medical care system has to be the health of our citizens rather than the health of a financial statement.

One test of any health care system is how it functions in a disaster or reacts to the sudden onset of a plague or an epidemic. In 1995, when the government building in Oklahoma City was destroyed by a massive bomb explosion, the health agencies of the area responded instantly and with the most admirable precision to save the lives of those few who survived. Praise was heaped upon the doctors who reacted so spontaneously to the call for help. Special accolades went to the medical team that dug deep into the rubble, which might have fallen on them at any moment, where they worked in darkness to amputate the leg of a woman trapped under a heavy slab of concrete that could not be moved. We have grown to expect doctors and nurses to do their best under the most perilous circumstances, which, as in the case of Oklahoma City, they invariably do.

But I am less impressed by our national response to plagues. These are unexpected eruptions of some unfamiliar death-dealing affliction like the spread of leprosy in Old Testament times, or the outbreak of the ancient plague in the London of 1665, or the strange attack of cholera among those journeying westward on the Oregon Trail in the 1840s, or the deadly pandemic outbreak of influenza in 1917. In the United States our medical system is currently engaged in fighting two modern plagues, and the battle reports are not encouraging.

AIDS:
One of the perplexities facing health care administrators is: ‘How should HIV-positive patients who can be expected to contract full-blown AIDS with its threat of early death be treated?’ AIDS must be handled as an epidemic that strikes across our entire population. That it has been associated in the media with homosexual behavior is only partly accurate; AIDS is also attacking the general population. (Indeed, the rates of increased cases are greatest among heterosexual young women.) We shoúld fund research to identify and distribute cures to halt the HIV infection but also provide hospices in which AIDS-afflicted people can die with dignity.

Tobacco:
Two aspects of our health program are so perverse they defy rational explanation. Since 1964, when the famous report of the surgeon general launched an attack on the health hazards of cigarette smoking, our federal government has aggressively campaigned against tobacco. Advertisements for cigarettes could not appear on television. Packages in which cigarettes were sold had to carry a government warning that they were hazardous to one’s health. Taxes were piled on cigarettes, and laws were passed forbidding people to smoke in public places. Millions of families posted
PLEASE DO NOT SMOKE
signs in their homes, and many public buildings such as libraries, hospitals and entire colleges and universities became nonsmoking areas. In addition, scientists
were remorseless with their barrage of studies that proved to the satisfaction of the general public that cigarette smoke by itself was carcinogenic if the nonsmoker inhaled enough secondhand smoke. Millions of two-pack-a-day smokers quit.

But while this government campaign was gaining new converts every month, our Congress was nullifying the effort by kowtowing to a powerful group of southern senators and congressmen who demanded that the government continue to protect the tobacco industry; the law even paid southern farmers subsidies to cultivate and market their tobacco crops. This bifurcated policy—condemn cigarettes but subsidize farmers to keep on producing huge surpluses—left many Americans bewildered, for they saw that they were paying twice for the cigarette: once when it was produced with a subsidy and a second time when hundreds of thousands of men and women contracted lung cancer and emphysema, leaving behind massive medical bills that often had to be paid from government funds.

The insanity of our tobacco policy was exacerbated when we exported our tobacco abroad and made it attractive for foreign governments to import our cigarettes and to endanger their own people. This three-pronged policy—condemn the cigarette at home, do everything to diminish its use within the United States, but pay farmers a subsidy so that their tobacco can be both marketed at home and shipped abroad to other nations—is a social crime with international reverberations.

This behavior on our part of forcing tobacco on other nations is reminiscent of the opium conflict of 1839–42, in which a powerless China sought to halt a nefarious opium traffic that was enervating her people but was defied by Great Britain, which earned a huge profit from the opium trade. Britain initiated what is known as the Opium War, and was joined by other European nations. The result was the imposition of duty-free ports along
the China coast inhabited and controlled by foreign powers. The United States participated in this shameful incident, and opium continued to be forced upon the Chinese.

I shall not belabor the analogy except to point out that for the last one hundred fifty years foreign historians have condemned Great Britain for her reimposition of the opium traffic upon a nation that did not want it.

T
o summarize, the components of a world-class medical system are already in place in the United States. What has been lacking so far is a firm resolve to pay the costs of welding the pieces together into a workable pattern that will meet the nation’s needs. I doubt that this can be achieved if we allow the insurance companies with their special interests to dictate what form that system will take.

I find it intolerable that our political leaders, those in charge of our plan of taxation, should propose a solution that would leave an enormous minority at the bottom of our economic ladder without reliable care or the insurance backing to acquire it. Other civilized countries have national systems of medical care to benefit all citizens, but the citizens are taxed to pay for it. Americans must be brought to realize both that medical facilities
must
be made available to all and they will be taxed to pay for them.

I consider health care to be one of the four most important issues on the national agenda. Not in order of priority they are: race relations, getting money to the dispossessed, education and health care. For me, improved race relations are a philosophical-moral imperative; helping the people at the bottom of the ladder is an economic necessity; education is vital if we are to continue to compete in world markets; health is a matter of life and death for all of us.

M
acho
is a Spanish adjective meaning ‘male.’ It would be improper to say: ‘He has
macho
,’ for the noun is
machismo.
To say ‘He has
machismo
’ would be proper usage, but in contemporary English the word
macho
has come to mean excessive or posturing male characteristics. The United States as a nation of active people has veered, I believe, toward a macho image of itself, and this is having an effect on many aspects of society. Macho ambitions explain, for example, why football has superseded baseball as our national pastime and why control of guns seems an impossibility. Among the deplorable effects of machismo in America are the complete degradation of many of our legitimate sporting programs, the ever-increasing numbers of children murdered by handguns, the rise of vicious militia organizations, the proliferation of vitriolic and dangerous radio and TV talk shows, and the depictions of violence in motion pictures that make violence appear to be a norm in life.

The seed of this emphasis on near brutality in American life was germinated far back in colonial times, when a man’s merit was judged by his ability to stand against all opposition in his community. He must subdue the land, defend his family and himself against danger and, when challenged by the local bully, stand up and fight. Even frontier sports for amusement could be very rough. Fistfights were bare-knuckled and often fought to the
complete exhaustion of one or both fighters; wrestling condoned gouging and punishing holds that would later be outlawed. The legacy of such exhibitions was a glorification of violence and the implanting of a belief that violence was a proper yardstick by which to judge a man and his games.