Friday, June 8, 2007
How the Greensburg tornado can help us rethink health care reform
BY RAYMOND DE VRIES

Surveying the wasteland that had once been the town of Greensburg, Kansas, President Bush said, ''While there was a dark day in the past, there's brighter days ahead.'' The president was in town to see the damage wrought by the F-5 tornado that flattened this town of 1500, to encourage the local residents, and to offer much-needed financial help with the rebuilding.

Love him or hate him, the president was there on our behalf, an incarnation of a value we Americans share: the importance of helping a neighbor in need. Almost no one objects when our hard-earned tax dollars bring relief to those whose lives are devastated by tornados and other natural disasters. Why then do we turn selfish when our neighbors’ lives are ruined by disease? Why are we willing to open our purses to the victims of a tornado, but snap them shut when are neighbors are struck with cancer, or heart disease, or Alzheimer’s?

Understanding this paradox is the key to changing the way we do health care in this country. Those who wish to see health care as a right of citizenship rather than a privilege of the well-heeled (or well-employed) have mistakenly assumed that the key to health reform lies in finding the right balance of incentives, taxes, co-pays, mandated services, and pay for performance schemes. But these well-intentioned (if not a bit Rube Goldbergish) plans for reform will fail if we do not first address our American ideas about neighborliness and individualism.

Most of us are aware of the sorry state of American health care: 45 million with no health insurance, average life expectancies that lag behind those of citizens in 47 other countries, and infant mortality rates higher than those of 40 other nations (including Guam, Greece, Portugal, and the Czech Republic). And yet we seem powerless to change this state of affairs. Sure, we know we can do better, and we are a bit embarrassed that we are the only developed country that does not offer health care to all its citizens. But when asked to change – as we were in 1994 when President Clinton introduced his “Health Security Act” – we balk. Do we really want the government choosing our doctor or our health care plan? What about those waiting lists for surgery?

The response of the policy wonk to this state of affairs is to try to devise a reform plan that appeals to everyone – the health insurance lobby, the unions, health caregivers, and corporate America. What these wonks fail to appreciate is the extent to which health systems are built on shared cultural ideas. The health care systems of other developed countries did not succeed because they managed to find a way to appease all those with a vested interest in health care. They succeeded because they were built on a common understanding of responsibility toward each other.

Of course, the United States is a difficult case: our attitudes toward health care represent a complex mix of values. This value conflict is well illustrated in John Q., a 2002 Hollywood film cum exposé of the injustice, maldistribution, and inefficiencies that attend medical care in the United States. John Q. is a laborer with a desperately ill son and inadequate health insurance. Frustrated by the restrictions and exclusions of his health coverage, he takes members of the hospital staff hostage and threatens to kill one of them if his son is not given life-saving surgery. Far from being reviled as a crazed terrorist (and this after September 11, 2001), John Q. becomes a hero, cheered on by Americans (and movie audiences) appalled by the injustice of a working class boy denied needed health care. The movie ends happily: the authorities are forced to relent and the boy is saved.

We Americans find this story pleasing because it appeals to two of our deeply held, albeit conflicting, values. On the one hand the film is a plea for fairness and solidarity – innocent children deserve care. On the other hand, it celebrates the brave individual, the “cowboy” hero who asserts himself, solving a social problem by acting on his own to get what he needs. Given this unresolved value conflict, how might we get Americans to endorse a health care system that provides universal access?

As in the case of the Greensburg tornado, current events give politicians and reformers the opportunity to remind us of who we are. When we see the president walking among the rubble, it reminds that we Americans do care for our neighbors. In a post 9/11 world, we also can be reminded how our individual freedom rests on caring for each other. Imagine, for example, a large city that falls prey to a biological attack. Hundreds of thousands are infected with a contagious virus. Would even the staunchest champion of free market health care suggest that the uninsured be denied access to treatment and turned back to the streets to infect others? In asking us to think about this scenario, reformers can appeal both to our sense of justice – victims of a terrorist attack should be treated regardless of ability to pay – and to our individualism – it is in my private interest to see that I am not infected by an untreated person.

We need our politicians and leaders to put down their pencils and their complicated plans for tweaking American health care. The necessary first step toward the repair of our broken health care system is not a complicated scheme that gives incentives for certain behaviors and discourages others; it is a public dialogue about the cultural values that drive our approach to health care. Anything less will doom the latest plan for change to the growing scrap heap of health care reform.

Raymond De Vries is a member of the Bioethics Program and the Department of Medical Education at the University of Michigan Medical School in Ann Arbor and the author of A Pleasing Birth.

Comment on this essay.

Comments are sent to the forum moderator. Select responses may be posted.

A Phony 'War on Science'
Michael Gerson, Washington Post
“In their talk of a Republican war on science, liberals may be blinding themselves to a very different kind of modern war in which their own ideals are deeply implicated: a war on equality.”

It’s Not Immoral to Want to be Immortal
Arthur Caplan, MSNBC
“Despite a lot of hand-wringing and finger-pointing, it is not obvious that wanting to live a lot longer is evil or immoral.”

Science Is Leading Us to More Answers, but It's Also Misleading Us
David A. Shaywitz, Washington Post
“Consumers of scientific information must balance the hope we place in global biology with the skepticism this field has surely earned.”

Taking the Scary out of Breast Cancer Stats
Carol Tavris and Avrum Bluming, LA Times
“The media understand how deeply women fear breast cancer, and the result is that every study that seems to find a link between some new risk factor and the disease makes headlines everywhere.”

Dollars to Doughnuts Diagnosis
Albert Fuchs, LA Times
“Insurance doesn't make routine care affordable; it makes it more expensive by adding a middleman.”

Tainted Medicine
Jerome P. Kassirer, LA Times
“Disclosure of financial ties may give a scientist or researcher a clean conscience, but that doesn't erase the possibility of a conflict.”

Children's health can't be left to faith alone
Arthur Caplan, MSNBC
“Parents do not have the right to watch a child wither away while they pray.”

Transplant List Numbers Raise Doubts
Arthur Caplan, MSNBC
“The American people have a right to expect absolute honesty about the number of people waiting for a transplant at any time.”

An Epidemic No One Wants to Talk About
Robert E. Fullilove et al., Washington Post
“Simply put, we will never rid the United States of HIV and other STDs if our only weapon is medical treatment.”

Making Cells Like Computers
Erik Parens, Boston Globe
“Conceivably, we are on the verge of installing synthetic genomes in bacterial cells to create products we want. But we are still a long, long way from doing what most people mean by ‘synthesizing life.’”

Miracle Workers?
David Rieff, New York Times Magazine
“Even today, the oldest of all relations between patient and physician — that of supplicant to shaman — continues to exert its authority.”

Overselling Overmedication
Judith Warner, NYTimes.com
“Most of the critics decrying the over-medicalization of the American mind rest their arguments upon the bedrock assumption that people who have nothing wrong with them are being medicated for largely fictitious concerns.”

Ads Spur Urge for Drugs
David Lazarus, LA Times
“DTC advertising has turned prescription drugs into just another gotta-have-it consumer product.”

Food Politics, Half-Baked
James E. McWilliams, New York Times
“Lost in this rhetorical battle was a quiet middle ground where the benefits and drawbacks of genetically engineered crops were responsibly considered.”

Perpetrating the Autism Myth
Benjamin Kruskal and Carole Allen, Boston Globe
“The scientific evidence is clear: neither the MMR vaccine nor thimerosal (mercury) in vaccines has any relationship to autism.”

Closing the Barn Door After the Cows Have Gotten Out
Verlyn Klinkenborg, New York Times
“The real beneficiaries are the nation’s large meatpacking companies — the kind that would like it best if chickens grew in the shape of nuggets.”

Human Embryos Cloned: What Does It Mean?
Art Caplan, MSNBC
“Let's not be frightened by scare tactics into not funding research that may be the key to curing what is currently incurable.”

Don’t Ask, Don’t Tell Is Bad Policy for Cloned Food
Art Caplan, MSNBC
“All of this fear-mongering about clones has made Americans forget that cloning is nothing more than artificially creating twins.”