healthcare, community, poverty, and policy

I just spent the last three hours listening to and talking with my new hero. Dr. Robert K. Ross, the president of the CA Endowment, whose goal is to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental imporvements in the health status of all. I was so jittery and excited and at one point almost started crying because he seriously outlined exactly what I want to do with my life and gave me tons of crazy cool new ideas, and it is so strange and yet wonderful to be affirmed in those ideas by someone much older, well-known, and generally brilliant. Here is my response to some of what he said:

Health revolution #1: The late 70s/early 80s made communicable and infectious diseases the most importand health care issue. If you want to hear about the history of AIDS watch the movie "And the Band Played On."

Health revolution #2: In 1985/86 crack cocaine became the new street drug of choice. It went from 100$ per hit to 5$. It is highly addictive, causes pain to go away, releases people from depression, and only lasts about an hour. The effects of cocaine are so much greater in a community oriented framework. Since the advent of cheap crack cocaine, life expectancy in inner cities has decreased. In 1990 in Philadelphia, the average life expectancy was 48. In 1980 it was 60. The statistics are similar for Southern California. Women get addicted and how do they get their money? Prostitution. Men get addicted and how do they get their money? Stealing and dangerous street trade. The prostitution breeds STDs and unwanted pregnancy. Cocaine induces muscle contractions, so babies are born too early. Stealing and street violence produces gangs. All of the above produces unsafe streets and home environments, and there is an entire generation of young people who grew up in houses and neighborhoods where these effects were very present. What is society doing for these youths now? What is society doing for the 1980s coke addicts now? One might ask, can we really extrapolate all of these effects from one cause: cocaine? Mostly yes, but fully no. But we shouldn't be ignoring the fact that the answer really is 'mostly yes.' LA and San Diego were hit the first and the hardest with cocaine trafficking, but it clearly has become a national problem. Economics is key here. The fact that cocaine became more abundent and cheaper effected the drug market in huge ways, which in turn effected every other systemic structure of society these cocaine addicts came into contact with, from neighborhood housing, to education, to healthcare. 1 in 3 men of minority status is destined to be a part of the criminal justice system at some point in his life as of 1990. Clearly, no part of society is left untouched by these statistics...who, after all, is paying for the incarceration of these men?

The second healthcare revolution comes to a close in the early 21st century with chronic, rather than communicable, diseases being the most talked about issue. This is largely because health care organiztions and individuals gave up on trying to deal with the problems of drug dealer and prostitutes and changed their focus to the poor. The shift in healthcare brought a focus on the chronic problems of the poor: diabetes, obesity, malnutrition, hypertension, bad eyesite, some STDs, and even cancers [not an issue of the poor as much, but definitely chronic].

Heathcare revolution #3: The closer look at chronic conditions has caused healthcare organiztions and individuals to look more closely at the healthcare system at large. Chronic conditions, after all, don't go away and require long term care, so the issue becomes a systemic one rather than a 'fix-it-once' solution. If you look up the word system in the dictionary, in no way does it describe what we have in terms of healthcare. People are starting to realize that the US spends more on health care than any other country in the world, and by no means has the best health. This third revolution is focused, therefore, around bringing health. That should be a 'duh' isn't that what heathcare is for. But if you look throughout the history of healthcare in America, it really isn't. Healthcare has been structured around reaction to problems rather than action and prevention. Reactionary care is absolutely important, but it will always be incomplete. Preventative healthcare economics is predicted to be the new and revolutionary field in the 21st century.

Take a guess: how much of your life expectancy right now is determined by the quality of healthcare you receive? Between 10 and 25% depending upon your healthcare plan. That is ridiculous!! So, what else is determining your life expectancy? Race, class, social status, gender, genes, and the way these things affect the social structures you interact with. [this is all from a legit study nationally recognized].

So when I say that the new healthcare revolution is focused on health, I really mean that it is focused on extending life expectancy. This will require tackling these other seeminly non-health related issues.

How to act: it is all about neighborhoods and community. And really, it's not just because that's what I'm passioante about. This is what all studies in the last 4 years have shown. Healthcare workers who are fed up with trying to work within the confines of the system are opting out and creating neighborhood and community organiztions [some of which have grown state-wide and nationally!]. There's a guy in Harlem who picked 20 square blocks to dedicate himself to. He has fully reformed the way the kids in that neighborhood get healthcare, education, and housing/supervision at home. On his wall he has a map of his 20 blocks of Harlem, and another map of the US with pins in the different cities where these once-street kids are now going to college. This stuff works! [and it's making me cry to think about it working :)].

What about the argument: this is too small-scale? That is a valid argument [though let's not discout the fact that the small-scale efforts are working!]. Here is where the policy makers and economists come in. So far, the benefits of small scale community health care have yet to be scaled up to fit a larger national context. There are two options: Find a way to unite and scale up the several small community focused healthcare groups, or encourage lots more of them to form in as many communities as possible. I would argue that both need to happen at the same time and that they will strengthen each other. How do we create a national healthcare structure that has all of the intimacies of neighborhood healthcare? Our problem isn't that we don't know what a good healthcare structure looks like. We do know. The last 10 years have given us success story after success story of non profits, independent hospitals, and clinics which have drastically influence the health of a community. We have the structure, now we need to find a way to fit it to a larger model.

Behold, I will bring to it health and healing, and I will heal them and reveal to them abundance of prosperity and security...And this city shall be to me a name of joy, a priase and a glory before all the nations of the earth who shall hear of all the good that I do for them. -Jer 33:6,9