POSITIVE POLITICS
Every public health decision also involves a political decision. Governments are the hope for public health and global health. Regardless of the high level of interest from church groups, NGOs, foundations, and service organizations, governments are the major funders of global health. While politicians may often be harmful to the health of people (as when they reduce support for immunization programs, refuse to expand Medicaid, or do not fund prevention in health care delivery programs), when properly motivated politicians can provide the strongest force in the world for positive change in health. Here is one example.
In early November 1979, Julius Richmond, surgeon general of the United States, called me to say that First Lady Rosalynn Carter was going to visit Cambodian refugee camps in Thailand, hoping to increase the world’s response to the problems of the refugees. Illness and malnutrition were major problems, and the current response was not yet equal to the needs. Dr. Richmond had been asked to accompany Mrs. Carter. His concern was that he knew nothing about refugee camps. Because he knew I had worked in the Nigerian Civil War relief operation, he asked whether I would accompany him. I agreed.
We were briefed by various persons and groups, including former Assistant Secretary of Health Phil Lee. What impressed me was how definite the opinions were regarding the conditions, disease rates, and death rates, and yet the estimates varied widely; there seemed to be little factual evidence for those opinions. Many of the assertions seemed to contradict what the last briefing group had asserted. On something as straightforward as malaria rates or death rates in camp, there was no agreement.
We flew on what would have been Air Force One, if President Carter had been aboard, and made one stop for refueling in Anchorage, Alaska. On the flight, I was asked what malaria prophylaxis Mrs. Carter should take. I was on my own and could not seek the advice of the CDC’s malaria experts. However, because of our time in Africa, I had followed the malaria prophylaxis and treatment literature to some degree. But now the saga of second-guessing began, and it ultimately led me to make the wrong decision—one that subsequently led to years of night sweats, as I would awaken to review my decision-making process on that trip. My first reaction, which was the correct reaction and the correct answer, was to say that we would be in an air-conditioned hotel in Bangkok for two nights and would be in the field only during the day, when mosquito bites are less frequent by malaria-transmitting mosquitoes. The risk of malaria would not be zero, but it would certainly be low. I had decided to take nothing myself, and I thought Mrs. Carter should not take any prophylaxis either. Then came the nagging doubts. What if the president’s wife got malaria and the director of the CDC had been the one to advise her to skip prophylaxis? Malaria experts reading this will wonder why this was such a hard decision.
I went to the next step of my thinking, when I should have stopped thinking altogether. I had used chloroquine in Africa for both treatment and prophylaxis of malaria. But that drug had shown resistance in Thailand, and it made no sense to administer an ineffective drug. I had been told that embassy staff and others in Thailand were using a drug called Fansidar, a sulfa-based antimalarial. Given their experience, it seemed the best choice, but there was a downside. It had, at that moment, not yet been approved by the FDA. So what would be the implications of using a drug not licensed in the United States, if we encountered a problem? Dr. Richmond and I discussed it and decided that Fansidar was still the most prudent approach. We would wait and have the embassy in Thailand get the drug for Mrs. Carter. And that is what we did. Everything seemed to work fine.
Years later, the rest of the story appeared, and that is what left me waking up sweating in the middle of the night. The CDC issued the MMWR each Friday morning. It combined statistics on disease occurrence with articles on current public health problems. When I was director, the protocol included a block of time every Wednesday noon for me to do a final review of the MMWR before it was sent to press. This started my habit of reviewing the MMWR every week. Thus, in January 1985, I was reviewing the issue that had a lead story on deaths from Stevens-Johnson syndrome following the use of Fansidar! (This syndrome can result in devastating lesions and ulcers of the skin and mucous membranes. It can lead to pneumonia and organ failure and is a distressing complication.) The possibilities continued to haunt me for many years.
In Thailand, Dr. Richmond and Mrs. Carter made the rounds of camps. She had asked me before we left, what risks she would be taking by holding refugee children. Dr. Richmond was especially concerned about tuberculosis. My response was that the risk was small but not zero. While some children in camp undoubtedly had tuberculosis, they were not great transmitters, and I thought the upside of her showing her concern for the children in camps outweighed the theoretical risk of disease transmission. Her innate concern for the children—the concern that had brought her there in the first place—won out.
In the meantime, I was able to spend the day with two experienced CDC employees, Roger Glass, a former EIS officer, and Joe Giordano, former public health advisor and program manager of the Epidemiology Program at the CDC. Having arrived only days before we did, they had made incredible advance preparations for our visit.
It was clear in the crowded camps that there was no room to bury the dead. Roger and Joe found that there was a contract for the removal of bodies and that while there were not records by individual name, the contractors did get different compensation for children than for adults. Therefore, there was a numerator of deaths for every day for adults and children. Moreover, there was a count of people as they entered the camp. Thus, it was possible to construct death rates by day for each camp.
Glass and Giordano had also found a Walter Reed team investigating malaria so it was possible to get malaria rates and treatment outcomes.
The population pyramid was telling. There were children younger than age 6 months, fewer than expected between 6 and 12 months of age, and then almost no children from ages 1 to 6. Clearly, children who were breastfeeding had an advantage, but children ages 1 to 6 did not compete well for food and were therefore almost nonexistent.
On the plane during our return flight, I briefed Dr. Richmond on our findings. He was so impressed that we actually had numbers and graphs that he asked me to brief Mrs. Carter. I told her about the information gathered on the population pyramid, death rates by day, and disease rates. When I showed her the figures on deaths per day, I was able to put them in a broader context. Because of my review of the literature during the Nigerian Civil War, I had information on what was known about death rates in refugee camps and was able to compare the findings to other historical events. I told her that I knew of no situation worse than the Leningrad blockade, a 900-day siege of that Russian city during World War II. Vital statistics were kept, and as I recalled it, the Russians reached their worst level just before a relief road over the frozen lake allowed Soviet convoys to enter Leningrad in January 1942. At that point, bringing in some food and removing some of the people became possible. Death rates, as I recalled, were at about 1 per 1,000 per day, or 36 percent on an annual basis. In the refugee camps in Thailand, death rates were actually at the same level when the camps were first formed but rapidly declined as medical and nutritional programs responded to the needs. This comparison to Leningrad reinforced the seriousness of the refugee experience in Thailand but also reinforced the belief that quickly responding to these needs was possible.
First Lady Rosalynn Carter at a refugee camp in Thailand. Photo from the author
Subsequently, a situation worse than Leningrad has occurred—the Rwanda genocide, where refugee camp death rates as high as 4 per 1,000 per day were recorded. At that rate, an entire camp would die in less than a year.
Several days after returning to the United States, the White House hosted a meeting, chaired by Father Theodore Hesburgh of Notre Dame, to hear a report from Mrs. Carter and to make recommendations on future actions. What happened next surprised me. The fact that Mrs. Carter was involved helped to mobilize efforts in both the United States and the world, and refugee aid increased in Thailand at an unbelievable speed. Once again I was reminded that every public health decision ultimately rests on a political decision.
Over time my interest in this relationship between politics and public health evolved. My early reaction was unhappiness with political decisions that hurt the public health through unnecessary suffering, early death, or compromised life quality. One day, my coworker Bill Watson took me to task, saying that the proper response to unwise political decisions should be to take responsibility. This led to the second step in my evolution. When politicians make bad decisions, he said, it is because they don’t have the correct information at the right time, and I should take responsibility for that. (In general, this is true, but in recent years, it is disheartening to see adequate factual information on global warming and gun deaths be readily available but ignored by political decision makers. Mark Twain once said the person who doesn’t read has no advantage over the person who can’t read. Likewise, persons who do not use their intelligence have no advantage over those who lack intelligence.)
I took Bill Watson’s advice to heart, and we began asking what information politicians needed and whether we were getting it to them. We redoubled our efforts, and, indeed, being proactive made a difference. But it is labor intensive to assemble and distribute information, and the turnover of politicians is so great that it is a continual education process.
The third step in my evolution was to urge public health workers to contemplate becoming politicians. It would be far more efficient, could only improve the debate, and would give me great comfort in my waning years to know that public health workers were in politics, making decisions on life quality.
How Public Health Should Be Funded
I am heartened by the political figures who made impressive contributions to public health. Senator Mark Hatfield, chairman of the Senate Appropriations Committee, was a consistent supporter of public health and global health. At my final appropriations hearing, Hatfield asked the subcommittee chair if he could conduct the hearing as a favor to me. One of his unexpected questions was how I would suggest public health should be funded. I wish I had anticipated that question.
My response was that the country could make several changes. First, for some public health programs, the financial benefits can be shown to exceed the financial costs. For example, benefit-cost analysis has demonstrated that every dollar invested in vaccine programs saves ten to twenty times that amount in the direct and indirect costs that would be incurred if the disease were not prevented. To not fund such programs means we not only continue to have the human suffering, but we also lose money in the process. That makes no logical sense on fiscal or humanitarian grounds. Therefore, my first recommendation would be that programs with proven positive benefit-cost ratios should become entitlements and no longer compete with other public health programs. To avoid battles between executive and congressional offices, my suggestion was that the responsibility of determining which programs are in that category should be left totally to Congress.
My second suggestion was that public health expenditures should be indexed to total health expenditures. Health care expenditures continue to increase over the years, whereas public health and prevention expenditures were declining as a percent of total health spending. I would be willing to accept whatever the ratio was at that point in time and fix that rate by indexing in the future.
These two changes would be rational and would provide long-term stability to public health efforts. But I would add a third suggestion. We have the audacity to advise other countries on health improvements, while having a totally dysfunctional and inefficient health care system in this country. As mentioned in an earlier chapter, two of the major barriers to improved health in the United States are (1) our inability to implement what we know in prevention and (2) the marketplace dominance of health care. Both problems are correctable.
The first problem is certainly made worse by inadequate public health resources, but it is also exacerbated by a system that penalizes attempts to deliver prevention in the health care system. Public health resources would be improved by my first two suggestions to the Senate subcommittee. But the inability of the health care delivery system to deliver prevention is criminal. Doctors are compensated for their interactions with a patient, usually to solve the complaint that brought them to the doctor. Physicians have guidelines on the average amount of time available for patients with various problems. But the system does not compensate physicians for time spent advising on tobacco use, exercise, diet, or safety measures. Therefore, practitioners cannot spend time on what they know would be useful to their patients and still make a living.
The marketplace is the other barrier, and it has failed the American public. Over a half-century ago, as I was completing my training, the American Medical Association bombarded us with materials on the King-Anderson bill, on how such efforts in political circles would reduce the freedom of doctors to make their own decisions and on the dangers of socialized medicine. Never did that organization point out that the marketplace might be more dangerous to the health of Americans than socialism would be. But that is exactly what has happened. When profit became the bottom line, quality, equity, and outcomes all suffered. Compensation began to focus on process, rather than on outcomes; the ease of measuring process, in terms of laboratory tests completed, CT scans performed, and the like, simplified paying for care. The great debates focused on quality, cost, and access rather than on quality, cost, and outcomes.
The marketplace is such a good mechanism for so many things that some assume it is a good mechanism for everything. Congressman Ron Paul once said that H1N1 flu is not something the government should respond to, that we should leave things this complicated to the marketplace. He made that remark only four years after the marketplace had demonstrated that it could not even manage the marketplace, much less influenza.
We simply cannot rely on the marketplace to reduce the health impact of tobacco when profits are made by selling tobacco. We cannot rely on the marketplace to reduce the risk of antibiotic-resistant bacteria. The great improvements in global health, in recent decades, are not the result of the marketplace. We should monitor the marketplace, and when it hurts the health of people, we need to find ways to correct the problem. Currently, the US marketplace has allowed the price of medical care to be higher per capita than any other country, and, despite that expenditure, we cannot even be in the top twenty countries of the world in terms of health outcomes. It is an absolute embarrassment for a country that prides itself on its can-do attitude and management skills.
Earlier I argued for a single-payer system. But is there a way to correct both barriers with one approach that uses the marketplace for delivery? Possibly. In 1993, the World Bank’s annual report focused on health. It unveiled a new metric called disability-adjusted life years (DALYs), which for the first time provided a logical approach to combining suffering and death into a single number. Suddenly, a reasonable way to decide on priorities and to make decisions on resource allocation was made available.
Expecting to measure health outcomes for each individual patient is fraught with problems. The problems with DALYs are known, and it should be possible to develop improvements to measure health outcomes in the aggregate. The next improvements in DALYs could include a way to measure life quality. It could also fine-tune the problem of life value at different ages and refine the estimates of the suffering caused by various conditions. And the measure of suffering as a percentage of death requires much discussion. It would then be possible to allot a percentage of the payments to health plans on the basis of health outcomes for the aggregate, even though much of the payment would still be based on process measures. Beginning with 5 percent or 10 percent of total payments on this basis could provide the incentive needed for health programs to focus on outcomes in addition to process.
A financial return to plans with better health outcomes would lead to incorporation of programs on smoking cessation, nutrition, exercise, and state-of-the-art education on diabetes and hypertension, to name a few. In short, there would be a reason to incorporate prevention practices into health care delivery because it would be profitable.
Success with this approach would allow other experimentation. For example, special financial incentives could be provided for improved health outcomes of defined special high-risk groups. These could include people who are overweight and those who have diabetes or hypertension, for example. This approach could provide financial incentives for enrolling the sickest people rather than the healthiest.
In this case, the marketplace could respond to specific targets, and it might be possible to demonstrate that we could again provide leadership to the world by improving health at a reasonable cost. It will require obsessive attention to prevention and the constant question, why prevention? To save money? … Yes, but it is far more than that. It is simply better to be well than sick, alive than dead, and healthy than disabled. The reason for prevention is to improve the quality of life.