Living the News: Health Care Refugee

Soon after the inauguration of US president Barack Obama, I posted an entry commenting on Pete Seeger’s  inaugural day performance of Woody Guthrie’s  “This Land is Your Land,” including near-forgotten verses of the song that had gone underground during the anti-communist hysteria of the McCarthy era.

Since then, another of Guthrie’s songs has been on my mind, “Dust Bowl Refugee.” Dust Bowl Refugee was Guthrie’s ode to the plights of American farmers during 1930s who, driven off their farms by drought, soil erosion, and bank foreclosures, trekked westward, working, when they could find work, as migrant agricultural laborers and casual laborers. (For the lyrics of Dust Bowl Refugee, click here).

My own present-day version of Dust Bowl Refugee has a title of its own, Health Care Refugee. I’ve spent most of the past winter in Istanbul, Turkey, partly out of preference and partly out of necessity. Indeed, you might say that I am a health care refugee.

My Netherlands-based health insurance — a policy I inherited from a job in the Netherlands in the 1970s and that I have maintained throughout my “career” as a peripatetic freelancer over the three decades since — recently stopped covering all but the most critical emergency medical treatment in the US.  Not surprisingly, the insurance company had finally balked at the astronomically over-inflated costs of medical care in the US.  But, niggardliness and tighter strictures on policy claims also mark a shift by Dutch insurers from a culture of dedication to policy-holders to dedication to investors and shareholders instead. Even as far away as the once rigorously social democratic Netherlands, it seems, decades of US prating against “socialism” and in favor of leaving individual and social welfare to the whims of an imagined “market place,” has cast its indelible shadow.

My alternatives were simple: Pay for needed health care out of my own pocket in the US (impossible), go to the Netherlands to seek treatment (this would require renting and maintaining an apartment there), go to Bulgaria (where I already maintain an office), or seek treatment in Turkey (where I had the chance to  “apartment sit” and the opportunity to avail myself of  library and research facilities).  The only two feasible options, thus, were Bulgaria and Turkey. The inadequacy of Bulgarian health care, the state of Bulgarian hospitals, and the characteristic unwillingness of Bulgarian doctors and dentists to admit and honor the limits of their know-how and abilities made the decision easy — I headed to Turkey.  And, thus, I joined the growing ranks of health care refugees.

What state of inequality or desperation would it take for health care refugees (with means and without) to compromise a counter-flow eastward and southward to worldwide flows of economic, human rights, and life-style refugees moving westward and northward?  The subject of flight is finally being broached in the press and in commercially sponsored studies (see, for example, this March article in the New York Times and a few paragraphs buried in this report from an accountancy-consultancy firm).

Balkan Medical Corruption and Under-Reporting

Last month, the Times also posted this article on corruption in hospitals in Romania, a situation not unlike that which causes me to do anything to avoid hospitalization in Bulgaria.  The article, however, is characteristic of much of the reporting on the eastern Balkans that appears in the Times, i.e. it treats long-standing problems and developments as freshly discovered news.  This particular story appears about 19 years too late.  Is this because the Times had consider the eastern Balkans to a news backwater or a training ground for reporters with no knowledge of the locale or interest in doing  research.  Or is it because in the 1990s and the Bush years, the US press was so self-satisfied with the “fall of communism” and the “end of history” that anything the “free market” brought with it, including inequities and corruption, seemed laudatory?  Well, better late than never, although…

Lobsters or Lard?  The Times or the old New York Post?

In debates on the relative worth of weblogs and the traditional press, I almost always weigh in in favor of the “mainstream media,” but the Times’s Balkan coverage makes me wonder.  So does this recent piece from Jane Brody’s venerable reporting on personal health.  The thrust: Americans who live on steak and lobster and “creme brulee” now should discover the what she calls the basics that got us through the last depression — potatoes and fruit, she writes, rather than white flour and lard, the diet of the poor today.  Americans who live on steak and lobster? Who is she talking about?  Not people on my planet and not people hurt by the present state of the economy.  And fruit rather than flour and lard in the Great Depression?  In the richest of households maybe.  What readership (or, more probably, advertising demographics) is the Times targeting?  Makes me long for Dorothy Schiff and the old New York Post, let alone the belated Bronx PM and the old National Guardian (all “google-able” for those who don’t know them).

Infrastructure of Work and Society: Five Failed American Axioms

Both sides in the US presidential campaign and debates — albeit one side far more than the other — use language and cling to axioms that obscure reality, make “change” unlikely, and keep America out of sync with the rest of the world. Five examples follow:

1. “American workers are the best in the world”

Nonsense. Americans may be decent sprinters but Western Europeans win the race. Good health care, regular vacations, job security, employee participation in management, lower stress, and no necessity to work two or three jobs to pay the kids’ educations makes Western European workers the world’s most productive. The growth of Asian economies speaks volumes about the quality of Asian workers just as does America’s outsourcing of its most exacting tasks to them. The diligence of Central and South American workers now bolsters America’s productivity through immigration. Turkish workers spend their lives laboring at highly segmented tasks. Even Eastern European workers are on their way to surpassing Americans. In alcohol-sodden Bulgaria, for example, workers tend to be “jacks of all trades and masters of none,” the upside of which is the ability to improvise and to more-or-less fix and keep running all things in their environment regardless of scarcities or systemic collapse.

2. “The Middle Class”

Both presidential candidates talks of helping the “middle class” but neither say a word about helping the working class or the poor. Avoidance of the term “working-class” is part-and-parcel of America’s pathological fear of “socialism.” It also belies the harsh reality that social mobility in America has been on the downturn since the 1950s. Not speaking of the poor is either callousness, blindness, or the abandonment of the tradition of the party of FDR and LBJ (let alone the party of Debs and or even that of LaFollette).

3. “Families”

Candidates speak of needs, opinions, and values of “families.” This in a country where the number of single and divorced adults rivals that of married ones and in which a good proportion of those nuclear families that are intact are dysfunctional. Since World War II, housing policies, suburbanization, and westward and southeastward migration have compromised multigenerational families (except amongst the poor and marginalized ethnic minorities), as has the Americanisation of immigrants. Eastern Europe and the “third world” have far stronger family values and structures. In fact, America may have proved itself to be a family-breaker and, through this, a compromiser of its own social infrastructure.

4. “We Honor Your Service”

Both candidates become Uriah-Heep-like in their obsequiousness when talking about the military or when speaking with present- or ex-servicemen. Obsequiousness toward the military was a hallmark of Franco’s Spain, Peron’s Argentina, and other tinpot dictatorships. It is also a matter-of-fact reality in countries such as Turkey, where, in an unusual balance of power, the military, with its proven willingness and ability to stage coups, is the guarantor of the survival of a secular state in a predominantly religious country. I would like to hear the candidates also “honor” America’s war and draft resisters for their sacrifices. A few words of “honor” and thanks for “service” to America’s lowest paid workers wouldn’t hurt either.

5. “Business is better than government”

This is the mother-of-all failed axioms, especially in the month when America’s iconic financial sector turns to the government for bailouts. During the last debate McCain trotted out this worn chestnut to denigrate Obama’s modest health-care proposals.

This brings us full circle. Universal health care is one of the features of European social infrastructure that ensures productivity by keeping health high and stress low. An important question for Americans is whether health insurance should be viewed as a luxury as it is now, a commodity as McCain proposes, or an essential aspect of social infrastructure as Obama proposes in part. The answer is not just a function of one’s morality but of one’s method of accounting. If one takes a longer and broader view, money invested in infrastructure — i.e. those physical and intangible systems and processes on which the social and economic life depend — pays off in macro terms even if initially developed or delivered at a short-term loss. The consensual nature of government and its operation beyond enterprise-level constraints of profit and loss make it the ideal provider or prime-mover when it comes to infrastructure. In fact, the provision and maintenance of infrastructure might be at the very essence of what government always has been, is, and should be.

Infrastructure and Height, Myopia and McCain

Since the 1970s I have worked mostly in Eastern and Western Europe, regularly returning to my native New York for occasional assignments and to enjoy the pleasures and pride of being a New Yorker.

When I first showed up in Western Europe almost four decades ago, the process of post-war recovery was not yet over.  As the years passed, however, I watched Europe slowly overtake America on a number of fronts, in part by engaging in long-term investment in its infrastructure and guaranteeing the health, education, and housing of its people as well as by curbing the extremes of economic inequality.

I’ve also watched changes in Eastern Europe since the fall of communism and seen the gaps in standards and ways of life between east and west narrow, especially as former Soviet bloc nations merge into the European Union.  From a New York perspective, European upswings are mirrored in shifts in the City’s immigrant populations, for example Irish and Polish immigrant communities have declined in size in part due to recent arrivals from both countries being lured back home by comparatively more attractive work opportunities and standards of living.

America, on the other hand, seems lost in a time-warp.  In this year’s presidential speeches and debates, as for what seems time immemorial, Democrat and Republican candidates prove their patriotism by repeating over and again the well-worn claim that America is the “greatest country on earth.”   America might have been so in the immediate post- World War II years but the disinvestment in social and physical infrastructure by the Republicans since the 1980s and the rapacious corporate culling of short term profits have undermined the country — as have the effects of the inappropriateness, extravagance, and incompetence of America’s military adventures abroad post-September 11, 2001.

Inadvertently, John McCain drew attention to an objective measure of this in last Friday’s presidential debate when he pointed out that residents of communist North Korea are, on the average, several inches shorter than fellow-Koreans living in the capitalist South.  What McCain did not say, however, whether out of ignorance or cynicism, is that over the last few decades Americans have become shorter than Western Europeans, over whom they had towered less than a century before.  For what this tells us about disparities in incomes and opportunity within the US, the consequences of the dismantling of America’s “welfare state,” and the absence of adequate insurance coverage and medical treatment in the country, go to this recent posting on the Health blog of the New York Times which, in turn, offers links to longer pieces on the subject from the files of both the Times and the New Yorker.

VRM and Health: A Country Without Databases, Individual-Oriented Medicine, and “Tasty!”

Further to yesterday’s entry on VRM (Vendor Relations Management) and health care …

In The Evidence Gap: A Call for a Warning System on Artificial Joints the New York Times reports that a plethora of unsuccessful joint replacement operations could have been avoided in the United States had there been, as there are in most other industrialized countries, national data bases of patients’ experiences.  Application of VRM to health issues not only has the potential to ensure delivery of properly individualized health care but also to assess and address the needs of groups of individuals and to broadcast the results back to policy makers and the medical industry at large (sadly, medicine is an industry in the US rather than part of a social net or service delivery infrastructure).

Two Health-Related Footnotes:

1. Individual-Oriented Medicine: Two days ago, I visited a “Park Avenue” (i.e. top-draw, high-priced) eye doctor for diagnosis and treatment of what I thought was damage to my right eye.  After a 20-minute examination for which I was changed US$ 395.00, the doctor said my eyes were fine but that I should see a dermatologist and have a general physical exam.  That evening I described my symptoms to a friend who for years works on-and-off as a translator at the office of a Russian-born Brooklyn eye doctor with a primarily Russian immigrant clientele.  Over the phone, my friend was able to diagnose what ailed me as a minor but persistent virus-related affair and suggest interim treatment.   He pointed out that even while functioning in the midst of the US insurance pyramid, some physicians in Russian immigrant neighborhoods still manage to respond to the situation of the patient rather than artificial distinctions between medical disciplines.

2. Tasty!  A recent posting on the New York Times’s Well Blog reported an overturn of the common-wisdom of the last decades re:eggs and cholesterol and also reported that alcohol is good for one not only because of cardiac benefits of red wine but also because drinking enhances quality of life.  Several years ago, over lunch in a restaurant garden in Sofia, Bulgaria, I asked my fellow-diner, an overweight hard-drinking ex-journalist suffering from high-blood-pressure and high-cholesterol, why he had ordered tripe-fried-in-butter, sausage, and feta cheese for lunch.  His answer: “Because it is tasty!” (Zashto e vkusno!)”  After I lectured him pedantically on the evils of cholesterol and sodium, he stared at the plate of sliced tomatoes and cucumbers that comprised my lunch and replied: “You will die of too little ‘tasty’ long before I die of too much cholesterol!”

Grandmother S. Redux: The Benefits of Early-Morning Schnapps and Mega-Doses of Red Wine

A couple of summers ago, I wrote a newspaper piece about my former summertime host and guru, Grandmother S. of the Black Sea village of K. in northeast Bulgaria, and the lessons I learned in her garden (click here for the full text and photos). Grandmother S. was well into her 80s at the time and still worked non-stop at subsistence farming. Her secret? Every morning at sunrise she drank a full-to-the-brim juice glass of homemade grape brandy on an empty stomach. “Styefko,” she used to tell me, “my brandy will give you the energy to work and will disinfect your stomach as well. But,” she advised, “drink it in the morning; morning drinking is good for the health, evening drinking is for alcoholics only.”

So, I took Grandmother S. up on her challenge. For three months, I arose at dawn and, before I allowed water, coffee, oatmeal, or yogurt to touch my lips, I downed a juice glass of Grandmother S.’s best homemade grape brandy (made with no seeds and with no sugar added to kick-start fermentation). The daily schnapps made me feel full of energy and raring to go. The only problem: I couldn’t think. Turning off the brain might help when faced with a day of hoeing vegetables but it can get in the way of writing, photographing, and even consulting.

I am reminded of Grandmother S.’s advice by Doc Searls’s link to this article in the New York Times announcing that red wine may be “potent” (sic) in preserving human longevity. Apparently, laboratory mice do better on treadmills when dosed with the equivalent of 35 bottles of red wine and humans may prolong their lives by drinking four five-ounce glasses of red per day. The article does not say whether the four glasses should be downed morning or night — but ever since the Judith Miller and Jason Blair affairs, I’ve tended to trust Grandmother S. more than the “newspaper of record.” From tonight on, I’ll keep my corkscrew next to my alarm clock.

Coda

Click here for a taste of Lambert, Hendricks, and Ross’s famed song Gimme that Wine. And, as the chorus of the song goes: “Unhand that bottle!”

More Balkan Lessons: Health Care Data and the Benefits of Dog-Eared Files and Messy Desks

One of the frustrations of working outside of the US on and off for much of my life is that Americans often react with irritation or hostility when I describe to them the benefits of “Big Government” in European social democracies. It seems beyond the comprehension of many Americans that Western European countries have actually developed and maintained powerhouse economies while also attending to an ethos of social responsibility and egalitarianism — to paraphrase the tone of Bush and Co.’s Iraq War rhetoric: How could cowardly, self-indulgent Europe surpass the world’s number-one democracy? Now, to their benefit and credit, Americans are beginning to wake up to the fact that they have cheated themselves and allowed themselves to be cheated, and that other nations have surpassed the US when it comes to taking care of their citizens. Michael Moore’s new film “Sicko” makes this point with Moore’s usual delightful bombast while the New York Times sums up the sorry state of affairs in this more somber editorial.

Health Care Chaos and the Democratization of Records

In a recent posting on the implications of the ever-narrowing gap between the US dollar and (!) the Bulgarian Lev, I described some facets of the economy and tone of post-communist Bulgaria and possible lessons to be learned from transformations and chaos in this small Balkan Republic over the last two decades, i.e. since the implosion of Communism. In the posting, however, I neglected to mention health care. Depending on which side of their country’s deepening gap between rich and poor Bulgarians fall, they have private or state insurance and visit expensive medical and dental clinics or are served by the country’s rank-and-file GPs and dedicated but overworked and ill-equipped public hospitals.

The single, but admittedly accidental, benefit of this unmanaged flux is that, for the moment at least, many Bulgarians have control of their own medical data, albeit without the adequate tools to administer them. Most Bulgarian doctors have neither the desire nor space to store records. Thus, their patients carry their own x-rays with them and pick-up and store their own blood-test and lab results. As a result, patients have a full set of printouts, film, and hands-scrawled charts with them most of the time — even if carried in dog-eared folders and stored on messy desk tops and in jumbled desk drawers. If they are interested and capable, and have sufficiently confrontational personalities, possession of such documents give them an inside track into understanding and maybe even managing their own conditions and treatment. Thus, once again, accidental circumstances in Bulgaria point to solutions for problems Americans face, in this case getting medical records out of the file cabinets and off the desks of doctors and, even if in duplicate, into the hands of the patients to whom they rightfully belong. The next step of course would be to set advanced information technology to work to support patients in setting data to work for their benefit and the potential benefit of others. The New York Times editorial linked to above underscored the urgency of this issue:

“Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.”

Not Just the Province of Giants

Some days later, the Times reported that Google and Microsoft have entered into the medical information management fray. But, as I wrote following a meeting with Vendor Relations Management activists at the Oxford Internet Institute back in July, there are numerous opportunities for grass-roots information projects (in this case a proposed community-based project serving diabetics in the UK) that can turn us all into managers rather than victims of medical care. We needn’t wait for industry giants, even if well-willing, to do the job.