“In this work against sickness, we begin not with genetic or cellular interactions, but with human ones” (Atul Gawande, Better, 82). Atul Gawande offers a perspective on scale: what is the goal of medicine if not to preserve humanity and quality of life? But the fact that Gawande is forced to point this out reveals a curiosity about medical “advancement.” When we depart from what is evident to the eyes, and senses, and zoom in on cellular reasoning, do medical providers forget the everyday levels of human functioning, the very levels they hope to preserve and improve for their patients? In this blog post I will examine the ways in which optimal health care reform must evade death while keeping it in view, by referring to examples from both T.R. Reid’s and Gawande’s reflections on health care.
When early philosophers advocated submission to reason, they couldn’t have appreciated the modern difficulty of weighing reasons coming from multiple scales and angles: the biological, the social, the psychological, temporal, economic, ad nauseum. But today, the extreme specialization of disciplines presents health care providers and each one of us with a wealth of different types of information to process. That’s a lot to expect a three-pound brain to sort out! Especially if that brain happens to belong to a sick body.
Clearly, health reform occurs, and must occur, on many scales. When we as a society attempt to navigate the health and wellness both of individuals and the populace as a whole, we have to ask ourselves quirky questions like: when is the individual story more telling than the mortality statistics?
T.R. Reid and Gawande have experiences that lead them to address the health care problem on different scales and from different angles. Where T.R. Reid’s book seems to focus on the need for legislation, Atul Gawande’s prescription asks for accountability from individual medical care providers and hospitals. Reid’s perspective comes from a global comparison as a journalist; he evaluates the systems of other industrialized nations and suggests that any solution must begin ethically and with universal coverage. Gawande too speaks from a global perspective, but as a surgeon, he sees improvement more in terms of inter and intrahospital operations. Gawande advocates a policy of “open information” so that clients can see and compare how well patients with certain afflictions fare at one institution vs. another. Gawande hopes that open statistics can do to other medical specialties what the Apgar score did to infant mortality rates. He recognizes how something as straightforward as access to numbers (mortality rates, life expectancy, other quality measurements) can foster healthy competition and “better” care.
Hand washing may save more lives than stem cell therapy and cancer vaccinesGawande, Better, p.233
A large theme of Gawande’s book has to do with the difference between bare knowledge and its implementation. If the goal of medical care is to save lives, the science of performance will have to catch up with science itself. For example, the numbers suggest that hand washing may save more lives than stem cell therapy and cancer vaccines (Gawande, 233).
Illness does not discriminate on the level of “scientific complexity”– it will seep in through whatever holes exist– in the mouth, the spirit, the economic netting, via laziness, no matter. If there’s a weak link in some aspect of our lives, there’s a potential for illness. Sometimes these holes are out of our control. But often habits, good and bad, add up. If you never floss, for example, you run a greater risk for tooth decay and potentially heart disease. If you exercise daily, you can improve your immunity. But neither of these habits are guarantees; they only affect the odds. And no matter how involved the story is of how we contract illness, in many ways the odds can be affected just as easily by complicated science as by simple science.
So this “work against sickness” belongs to many people beyond scientists: providers, insurance companies and legislators, individuals, and nations. Gawande’s “human interactions” therefore involve many types of humans: some versed in medicine, others in economics, others in ethics and humanities, others merely in personal concern. All of these considerations clash and collide, and inevitably, some don’t make it out alive.
With a bureaucracy, it is not always obvious who is responsible for a “preventable” death. Reid therefore attacks the bureaucracy itself as a failing, and enforces his argument with Nikki White, the perfect example of a victim of the United States health care system. A fit 32-year old that dies of treatable lupus because she doesn’t have insurance, Nikki’s real story exemplifies the fear that motivates health at its most primitive level: the risk of mortality even at a young age. The very idea that one can have their health insured does not mean that health can be ensured, yet we consider insurance the “next best thing” to ensurance; if something happens, at least I’m assured medical aid.
The most human threat to autonomy and power is our capacity to die. But we’d like to believe that with the advancement of human medical knowledge comes the ability to create infrastructure in which no one need die or suffer when an ailment is preventable or curable. It is frightening to realize, however, that the mere availability of knowledge is not enough to assure one’s access or even good use of it. If access to knowledge was an inalienable right, more humans might have read the wealth of wisdom available to us regarding how to understand and train the mind and body, and maybe we would all be more individually responsible and have different or fewer insurance needs overall. Regardless, we understand that medical care has a special ranking among the human concerns, since in a moment of need, it affects and/ or determines our very existence.
We all have deep personal reasons for wanting to reform or ignore health care. Our reactions probably parallel the reactions we have to death and grief. Some people prefer to “cross that bridge when they get there”, holding out without health insurance until it becomes absolutely necessary. Others want a preventative approach, but it’s not always clear where to start. And still others focus on personal responsibility for their own health and wellness. But what we worry about are the exceptions: the healthy people who “have” health insurance until they get sick. When Nikki’s lupus prevented her from working, she lost her insurance precisely when she lost her job at the hospital. Talk about tragic irony. If we limit the scope of the legislative problem to cases like Nikki’s, we might find that the situation isn’t as messy as we thought. Each one of us can and should practice Gawandian diligence in taking charge of our own health, in knowing our own bodies, but as Reid points out, the government should be there to catch us when we fall or find ourselves being the exception. Obviously the fact that “we cover everybody; we don’t cover everything” shouldn’t stop us from trying to discover fair floors and ceilings for the treatment of United States citizens.
What unites Reid and Gawande are appeals to brute force and common sense. I can understand this. During my two summers in Radiology research at Mayo Clinic, I began to stare blankly at the theoretical equations in the papers I read (or was co-author of!) explaining the photon statistics of x-rays and the elimination of “noise” from the algorithms. I realized what an interesting and difficult task the tradeoff between noise and image quality is, and that there are a lot of philosophical questions about “quality” the researchers have to answer based on the broad spectrum of patients and diseases they see each day. But I also realized that for terminal patients, or even moderately ill patients, the risk of cancer from radiation from CT or MRI scans is effectively negligible. No conclusive metric could be assigned linking radiation scans to cancer because the numbers were so fuzzy. But any physician looking at the “whole patient” could have quickly discerned the value of a noninvasive medical image for most of the patients I saw. And as long as radiologists were careful about protocols, radiation probably wasn’t the most immediate threat to their life. But the research team seemed to be united against a stream of headlines spouting the “dangers” and “horror stories” of CT scans. Sometimes we have to simply take a step back and think about life at scale and in time. Gawande’s stories about emergency, war, and third-world medicine are valuable because humans live relatively short-life spans. If we spend more time being idealists than pragmatists, we are essentially acting ignorant of mortality. At some point, ethical questions about the human condition will catch up to those of science because our lives are fleeting. And in that sense, the work against sickness is always a noble yet losing battle.
The Humanitarian in me cries, “what if we dispense of the war metaphors all together and start running toward life?” A resilient brain knows that absolute safety is impossible. Risk management is the best we can do. And if we come to our senses, they can help us manage that risk quite a lot.
Atul Gawande (2007), Better: A Surgeon’s Notes on Performance
T. R. Reid (2009), The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care