Medical screening, overdiagnosis, and the motives of for-profit hospitals

Image by @spleenal (Nigel Auchterlounie), who blogs at Spleenal
Image by @spleenal (Nigel Auchterlounie), who blogs at Spleenal

This superb graphic was created to dramatize what’s happening these days in the UK, where the National Health Service is being ruthlessly privatized. Here in the US, for-profit medicine is so taken-for-granted that we barely notice it. It’s true, we hear a good deal about conflicts of interest involving pharmaceuticals. Doctors get paid — in one way or another — to increase the profits of Big Pharma, a practice that is detrimental to the financial and/or medical interests of their patients. We hear less about scaring healthy patients into using doctors and services that increase hospital profits (also known as fear mongering). So it was nice to see a recent opinion piece in JAMA that discussed precisely this.Read more

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How we came not to care: Oligarchy of the elite

Side View of Statue of John Harvard by Daniel Chester French

The final post in this series on interrogating inequality is about another possible clue as to why we no longer seem to care about inequality. It’s from the book Excellent Sheep by William Deresiewicz.

The role of elite institutions of higher education

In his book, Deresiewicz argues that elite educational institutions reproduce a class system, exacerbate inequality, retard social mobility, and perpetuate privilege. Not only is the elite class that’s created by these institutions “isolated from the society that it’s supposed to lead.” It runs society for its own exclusive benefit. (emphasis added)

Our educational system, it’s been suggested, is what America developed in lieu of a European-style social welfare state to mitigate inequality. Instead of “handouts,” opportunity. And once upon a time, it worked as advertised. Both the unprecedented expansion of public higher education and the equally unprecedented opening of access to the private sort were instrumental in creating a mass middle class, and a new upper and upper middle class, in the decades after World War II. But now instead of fighting inequality, the system has been captured by it.

I mention this not simply as another possible clue, but because the article (Rebooting Social Science) that prompted me to write this series of posts appeared in Harvard Magazine. That may or may not be relevant to the attitude it expresses towards inequality, an attitude I found troubling.Read more

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How we came not to care: Historical trends

homeless-on-wall-street

Continuing my discussion of interrogating inequality, here is another post with a possible clue as to how we came not to care. This one considers a rather wide expanse of history

We have neglected to cultivate a culture that cares

I recently struggled through the book Governmentality: Power and Rule in Modern Society by Mitchell M. Dean. The book is very clearly written — the publisher calls it “exceptionally clear and lucid,” and it is. The book is intended, however, for experts already familiar with Foucault’s writings and lectures, particularly those on governmentality.

I frequently found myself in a fog, but I persisted. I was hoping to find ideas that would explain the changes that produced the contemporary self, including why we have become a society that fails to care about increasing inequality. And I did find a brief reference to this development in a section where Dean asks: “Where do our notions of ‘care’ come from?” Why do we think the state should care for the welfare of its citizens?Read more

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How we came not to care: Rosanvallon

rosanvallon-the-society-of-equals

How did we become a society that passively accepts the injustice and discrimination inherent in inequality? How did we come not to care? It would undoubtedly take me a very long time to adequately address that question, but in this and the next two posts I offer a few small clues.

We are each the stars of our own lives

First up is Pierre Rosanvallon’s recent book The Society of Equals. In a review of the book, Paul Starr mentions what may be an impediment to a society of equals: We see ourselves not simply as individuals, but as unique singularities. (emphasis added in this and the following quotations)

The story that Rosanvallon tells here is that as new forms of knowledge and economic relations have emerged, people have come to think of their situation in less collective ways. Since the 1980s, he writes, capitalism has put “a new emphasis on the creative abilities of individuals,” and jobs increasingly demand that workers invest their personalities in their work. No longer assured of being able to stay at one company, employees have to develop their distinctive qualities—their “brand”—so as to be able to move nimbly from one position to another.

As a result of both cognitive and social change, “everyone implicitly claims the right to be considered a star, an expert, or an artist, that is, to see his or her ideas and judgments taken into account and recognized as valuable.” The demand to be treated as singular does not come just from celebrities. On Facebook and many other online sites millions are saying: here are my opinions, my music, my photos. The yearning for distinction has become democratized.

Rosanvallon does not criticize the society of singularities, with its “right to be considered a star.” Since it’s now a fact of life, we need to figure out how to deal with it.Read more

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Interrogating inequality: Tony Judt

call-the-midwife-nuns

In a previous post (Interrogating inequality: An annoying article) I discussed an article about a group of interdisciplinary scholars who were “interrogating” the societal consequences of increasing inequality. While the group included individuals with backgrounds in psychology and history, it was dominated by academic scholars who specialized in economics, business, and public policy. (The first three individuals quoted in the article are a professor of business administration, a professor of management practice, and a senior lecturer at Harvard Business School.)

The concluding comments on inequality were offered by a professor of social policy. This particular individual “recently revealed” that he had given up on his long-term research on the social effects of inequality (a project he’d started in the 1960s) because there were no “convincing conclusions.” In other words, research had not been able to provide statistical proof that inequality is in any way harmful to society as a whole. As one of the social scientists put it: (emphasis in original)

The problem is, there is no consensus in the research on the consequences of inequality.

May I suggest that a more significant problem is that social scientists ask the wrong question. As Tony Judt writes (emphasis added):Read more

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Interrogating inequality: Some good news

childhood-mechanisms-health-inequality

The previous post, this post, and the next four were provoked by an article that made two assertions I found troubling: one, that there is no consensus among researchers on the consequences of inequality, and two, that evidence of a “causal relationship” between income inequality and health is unclear. In the last post, I discussed those assertions and quoted Daniel Goldberg on whether health behaviors determine health. To continue …

Ground control, we have causation

Over the past few months, since I first read that annoying article, I keep coming across accounts that offer evidence of the harms that result from inequality (particularly in childhood), as well as actions that doctors and politicians are willing to take to address the problem. We’ve known for some time that there was a correlation between poverty and health. Now we’re finally discovering the mechanisms, the causation.Read more

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Interrogating inequality: An annoying article

interrogating-inequality

I recently read an article that really annoyed me. It was called “Rebooting Social Science: The interdisciplinary Tobin Project addresses real-world problems.” I began to realize that I wouldn’t see eye to eye with this article when I got to the section that discussed the “real-world problem” of inequality. The section was titled “Interrogating Inequality.” Not “addressing” inequality. Interrogating. Shades of “doubt is our product,” as I’ll explain.

One of the scholars interviewed for this article characterized inequality as “the most contested of contemporary issues.” The evidence cited for said contestation was the lack of agreement on whether inequality contributed to the recent financial crisis. Some claim that it did. Others, however,

dismiss this argument, viewing rising inequality “as little more than a hiccup” or even celebrating it as “a favorable development … in the progress of American capitalism.”

As it turns out, the real issue being “contested” by these “social scientists” (economists, not sociologists) is not whether inequality exists or whether it’s just a hiccup or an inevitability of capitalism. No. (emphasis in the original)

The problem is, there is no consensus in the research on the consequences of inequality.

No consequences? What about childhood trauma, increased rates of disease, shorter lifespans, human dignity? Well, it turns out those things may affect individuals, but what these researchers are looking for are societal consequences. For example, is there a relationship between inequality and economic growth? Evidently, if we cannot detect a decrease in economic growth, there’s no reason to alleviate inequality. And it seems social scientists disagree among themselves about the quality of the evidence on that issue.Read more

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Big Data, privacy, and civil disobedience

privacy-big-data-civil-disobedience

Back in May, Evgeny Morozov wrote a review for The New York Times Book Review of two books: The Naked Future: What Happens in a World That Anticipates Your Every Move? by Patrick Tucker and Social Physics: How Good Ideas Spread — The Lessons From a New Science by Alex Pentland. The review is excellent. I’m mostly going to quote from this review (plus one of Morozov’s books), since this is a huge topic in which I have considerable interest but no expertise. I’ve been thinking about a JAMA article I read recently that discusses the need to convince the public to allow extensive use of Big Data in connection with health care (What’s that you bought at the grocery store? You didn’t renew your gym membership?), and Morozov’s ideas seem related. (Morozov, by the way, considers Big Data an “ugly, jargony name.”)Read more

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The Journal of Medicine and Philosophy — August 2014

sports-doping

The August issue of The Journal of Medicine and Philosophy does not have a specific theme. The nine articles address a number of quite interesting issues, among them:

  • How existential psychotherapy can offer powerful insights to patients recovering from severe mental disorders such as psychosis
  • How a preference in athletics for natural talent over artificial enhancements (such as doping) may reflect “unsavory beliefs about ‘nature’s aristocracy’ ”
  • How rich, educated, white males may be just as, if not more, vulnerable to threats posed by physician-assisted suicide and voluntary active euthanasia than members of marginalized groups
  • When the decision is made not to administer artificial hydration and nutrition, can the responsibility for the patient’s death be attributed to the underlying pathology, even when that is not the cause of death
  • The right to procreate: Is it possible for prospective mothers to wrong prospective fathers by bearing their child

Note that the articles in this journal are not open access and that I have added the emphasis in the following extracts and abstracts.Read more

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Social history of medicine — August 2014

history-of veterinary-medicine

The August issue of Social History of Medicine contains eight original articles:

  • Late 19th/early 20th century food adulteration in an increasingly industrialized and globalized world and the search for safety standards
  • The shift in cancer education in the 1950s, no longer downplaying post-operative recovery
  • The 20th century shift in British veterinary medicine towards small animals (dogs, cats), as the need to attend to horses declined (open access)
  • How complaints about the quality of London drinking water in the 18th century reflected the new popularity of bathing for health and social attitudes towards bathers from the lower classes
  • A re-evaluation of the prevalence of venereal disease at the time of the World War I (open access)
  • How quacks preyed on people with hearing loss in mid-19th century Britain
  • How the 1975 TV play, ‘Through the Night,’ portraying what it was like to experience breast cancer treatment, registered with medical professionals and activists who complained of ‘the machinery of authoritarian care’ (open access)
  • Did Axel Holst and Theodor Frølich actually develop an animal model of experimental research?

There are also a large number of book reviews, including:

  • Writing History in the Age of Biomedicine by Roger Cooter with Claudia Stein
  • Emotions and Health, 1200–1700 by Elena Carrera (ed.)
  • The Age of Stress: Science and the Search for Stability by Mark Jackson
  • Before Bioethics: A History of American Medical Ethics from the Colonial Period to the Bioethics Revolution by Robert Baker

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For-profit medicine and why the rich don’t have to care about the rest of us

rich-poor-inequality-neoliberalislmJill Lepore has an article in a recent New Yorker called The Disruption Machine: What the gospel of innovation gets wrong. Her target is Clayton M. Christensen’s book The Innovator’s Dilemma and, specifically, disruptive innovation. As usual with Lepore, her essay is personable and well-argued. What I liked most about it, though, was its brief discussion of how unfortunate it is that professions such as higher education and medicine are being privatized (if they’re not already) and administered to maximize efficiency, making profits more important than students or patients. (emphasis added)Read more

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Why women should not ride bicycles: The medical opinion in 1896

women-bicycles-19th-century

In the 1890s, bicycles became safer and more comfortable to ride (detailed in this Wikipedia entry on the history of the bicycle). This may have something to do with the increased number of women who were attracted to bicycle riding. (There’s a correlation, but the causation is undoubtedly much more complex.)

Some celebrated this development. Susan B. Anthony, for example:

Let me tell you what I think of bicycling. I think it has done more to emancipate women than anything else in the world. It gives women a feeling of freedom and self-reliance. I stand and rejoice every time I see a woman ride by on a wheel … the picture of free, untrammeled womanhood.

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Journal of the History of Medicine and Allied Sciences – July 2014

adelle-davis-books

In the July issue of Journal of the History of Medicine and Allied Sciences:

  • A comparison of 19th century public health measures and the contemporary approach to the AIDS pandemic
  • The conflict between the medical profession and religion in their attempts to portray habitual drunkenness
  • The understanding of dementia paralytica in the Netherlands at a time when psychiatry was attempting to establish itself as a medical profession
  • Adelle Davis’ role in creating the ideology of nutritionism.

There’s also a commentary on the Adelle Davis article, an ‘In Memoriam’ for Sherwin B. Nuland, and reviews of ten books (of which I’ve featured here only two).

Thanks to h-madness (a great blog) for bringing my attention to this new issue. Somatosphere (a most excellent blog — highly recommended) often covers this journal, but I haven’t yet seen the July issue there, so I’ll go ahead and post these abstracts. Note that all articles (other than their abstracts/extracts) are behind a paywall. (emphasis added in what follows)Read more

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The Journal of Medicine & Philosophy – June 2014

cognitive-enhancement

The theme of the June issue of Medicine & Philosophy is disagreements among bioethicists. This is an interesting topic in its own right (see the extract from the Introduction to the issue below), plus there are a few articles that especially appealed to me. The discussion of cognitive enhancement appears to argue for a more tolerant attitude toward enhancement drugs based on an attitude of humility, plus toleration and transparency. There’s also an article that points out how we assume the art of clinical medicine is an innate skill and that, as a result, we fail to teach it.

Note that nothing is this journal is open access (and also that I have added the emphasis).

Introduction

Bioethics and Disagreement: Organ Markets, Abortion, Cognitive Enhancement, Double Effect, and Other Key Issues in Bioethics

Victor Saenz

I. BIOETHICS AND DISAGREEMENT

Bioethics was born in the 20th century out of an attempt to cope with rapidly and radically developing medical technologies, especially as they arose around the time of the Second World War. Albert R. Jonsen, one of the founders of bioethics, writes in reminiscence:

New techniques, from antibiotics to transplanted and artificial organs, genetic discoveries, and reproductive manipulations, together with the research that engendered them, presented the public, scientists, doctors, and politicians with questions which had never before been asked. (Jonsen, 2000, 115; cf. Jonsen, 1998)

But more importantly, bioethics arose as well due to major cultural changes that marginalized previous approaches to moral issues in health care and that brought into question medical ethics as an enterprise grounded in the medical profession.Read more

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Drug shortages: “We are talking about people’s lives; this is not a cell phone contract”

iv-fluidThe shortage of pharmaceutical drugs is a serious problem in the US. The number of drugs in short supply has tripled since 2007. In an article in The New York Times, Sabrina Tavernise reports that the number of drugs in short supply in 2012 was 456.

The types of drugs affected cover a very wide range and include such things as cancer drugs and nitroglycerine used in heart surgeries. The situation is quite disruptive for hospitals, doctors (especially oncologists), and patients.

IV fluid shortage threatens patient care

This year, in addition to drug shortages, there is a nationwide shortage of IV fluid. Intravenous therapy is essential for treating dehydration and electrolyte imbalances, for blood transfusions, and for delivering medications such as those used in chemotherapy. IV fluid is a hospital staple.

A recent JAMA article quotes Erin R. Fox, director of the Drug Information Service at the University of Utah in Salt Lake City: (emphasis added in the following quotations)

“It’s maddeningly frustrating that we don’t have these basics.” … Fox said that although shortages of drugs, particularly sterile injectables, have become common in recent years, it is unheard-of to have a shortage of such a basic supply. …

Why is the supply chain so fragile that it creates a national crisis? asked Fox. …

“Physicians, nurses, and pharmacists are working together to minimize the harm to patients, but it is really a challenge,” she said.

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Going extinct

Red-eyed tree frogs
Red-eyed tree frogs
Animal species are going extinct at a rate thousands of times faster than was the case before there were humans. And this is a conservative estimate.

At least half the tortoises and turtles, a third of the amphibians, a quarter of the mammals, and an eighth of the birds on this planet face a risk of extinction in the near future. What’s worse, these numbers apply only to the small fraction of known species whose conservation status has actually been assessed. The overall picture is likely to be much worse.

This from a review of the book The Sixth Extinction: An Unnatural History by Elizabeth Kolbert. The reviewer is columnist and author Verlyn Klinkenborg (The Rural Life).

It’s not just climate change. It’s our way of life.

It’s not just climate change that accounts for the increased rate of species extinction. (emphasis added in the following quotations)

The general tendency of our species—a tendency that seems to be intensifying all the time—is to decrease biological diversity on this planet. We do so by destroying habitats, overconsuming natural resources, and spreading invasive species, willingly or not. It’s tempting to say that this is the cost of consciousness. We like to imagine that cultural diversity is an adequate substitute for biological diversity—for ourselves, if not for other species. It isn’t.

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Climate change and deconstruction

Home in Union Beach, NJ after Hurricane Sandy
A home in Union Beach, NJ after Hurricane Sandy
In a recent essay on climate change, Zadie Smith touches on matters not usually mentioned in connection with this topic. “What’s missing from the account,” she says, “is how much of our reaction is emotional.”

Smith is the mother of two young children. She imagines how, in the year 2050, she would explain to a hypothetical granddaughter why previous generations failed to act. (emphasis added)

I don’t expect she will forgive me, but it might be useful for her to get a glimpse into the mindset, if only for the purposes of comprehension. What shall I tell her? Her teachers will already have explained that what was happening to the weather, in 2014, was an inconvenient truth, financially, politically—but that’s perfectly obvious, even now. A global movement of the people might have forced it onto the political agenda, no matter the cost. What she will want to know is why this movement took so long to materialize. So I might say to her, look: the thing you have to appreciate is that we’d just been through a century of relativism and deconstruction, in which we were informed that most of our fondest-held principles were either uncertain or simple wishful thinking, and in many areas of our lives we had already been asked to accept that nothing is essential and everything changes—and this had taken the fight out of us somewhat.

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Teaching the oligarchy not to care

Abimbola "BIM" Fernandez at home
Chris Hayes sometimes gets dismissed as just another commentator on a failing liberal TV network, but I found his book Twilight of the Elites a perceptive, well-written account of how American meritocracy perpetuates inequality.

Hayes recently reviewed the book Young Money: Inside the Hidden World of Wall Street’s Post-Crash Recruits by Kevin Roose. The book follows the lives of eight young men — recruited to be investment bankers — during the first two years of their employment on Wall Street.

I especially liked this passage from Hayes’ review:

Why, one might ask, in an economy in which 49 million Americans are poor and the median household income hovers around $51,000, should we care about the psychic plight of 23-year-olds making $90,000? Because these are the people who run our country, and the process by which their own empathetic faculties are destroyed is a key part of how this entire corrupt finance-state is maintained.

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Pharma finds creative new ways to be reprehensible

brand-vs-generic-drugsThe pharmaceutical industry is in the business of making profits. It’s not in the business of improving the health of individuals or populations, nor does it care about the cost of health care, even as those costs spiral out of control in the US.

This is hardly news, I know. The behavior of pharma, along with its reputation, has perhaps sunk lower than that of the tobacco industry. Public disapproval and huge monetary fines for illegal activities have no impact. In its quest for profits, pharma finds creative new ways to sink to ever greater depths.

An article in a recent issue of The New England Journal of Medicine illustrates this. Read more

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For U.S. health care, some are more equal than others

death-rate-after-surgeryThe Affordable Care Act (ACA, aka Obamacare) will expand insurance coverage to millions of Americans (for example, to individuals with pre-existing conditions). Having insurance, however, does not mean a primary care physician will be willing to take you on as a new patient. There are multiple reasons for this, as discussed in a recent article in JAMA, Implications of new insurance coverage for access to care, cost-sharing, and reimbursement (paywall).

We no longer live in the Marcus Welby days of a medical practice that has only one or two doctors. The “vast majority” of primary care practices, however, have only 11 or fewer physicians (according to JAMA). Many of these practices are already at or near capacity, which means that adding new patients may require additional expenses (staff, office space, equipment). For small practices, the decision to add new patients is first and foremost a business decision: Will the increased income cover my increased expense? Here are some of the things the “vast majority” of providers will be thinking about:

  • The ACA lowers the cost of health insurance for many individuals, in particular, for people with relatively low incomes. These patients, however, will pay more for health care itself due to higher co-pays (that part of the cost not covered by insurance) and higher deductibles (the maximum annual out-of-pocket expense). In the past, the main burden of collecting fees was on insurance companies. Under the ACA, it may be health care providers who are faced with a “collection burden.”
  • Read more

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When healthy eating becomes unhealthy

healthy-eating-orthorexiaMeghan O’Rourke, poet and author (Halflife: Poems, Once: Poems, The Long Goodbye: A Year of Grieving), has written a wonderful piece for The New Yorker on living with a chronic illness. It’s called What’s Wrong with Me? I had an autoimmune disease. Then the disease had me.

For years O’Rourke experienced symptoms that she tried to attribute to her latest source of stress. Doctors were unable to offer a diagnosis, a situation that tends to suggest the suspicion that the symptoms may be all in your head.

She writes: “I was ill for a long time — at least half a dozen years – before any doctor I saw believed I had a disease.” Eventually, after she received a label for her symptoms (autoimmune thyroiditis or Hashimoto’s disease), she connected to the online community of chronic disease sufferers. There she found not only a great many individuals with similarly frustrating histories, but an abundance of home-grown advice for the relief of symptoms.

A more or less definitive diagnosis for a disease that is only vaguely understood may at least confer some legitimacy on one’s status as a patient (for an historical perspective on diseases that do not fall neatly into diagnostic categories, see Robert Aronowitz, Making Sense of Illness .) The individuals who suffer, however, are still very much on their own when it comes to recovery and the alleviation of symptoms. Thus the home-grown advice.

Orthorexia and healthism

What I’d like to focus on in this post is one small part of O’Rourke’s narrative: her attempts to alleviate her symptoms through a growing obsession with the selection and control of the food she ate. It’s not difficult to find media stories and blog posts that put a positive spin on (what amounts to) an excessive preoccupation with healthy eating. It’s rare, however, to find an experiential account that recognizes the obsessive pursuit of health as itself unhealthy.

A classic discussion of the latter is Steven Bratman’s Health Food Junkies: Orthorexia Nervosa – the Health Food Eating Disorder. In O’Rourke’s case, of course, she was not simply eating to be healthy. She was seeking relief from very real and disturbing symptoms. That’s not quite the same thing as orthorexia, although both provide the health food consumer with an opportunity for reflection.Read more

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Neoliberalism, tobacco, and public health (2)

The occasion for the rambling reflections on neoliberalism in the previous post was three “perspective” articles on tobacco in a recent issue of The New England Journal of Medicine. Two of them concern the FDA’s attempt to place graphic warnings on cigarette packs. The other is on cigarette smoking among the homeless.

The First Amendment

fda-graphic-warning-labels-cigarettes-are-addictivePlacing graphic warnings on cigarette packs was part of the 2009 Family Smoking Prevention and Tobacco Control Act. The tobacco industry sued the FDA (R.J. Reynolds Tobacco Co. v. FDA), claiming the warnings violated the industry’s First Amendment rights. In a case decided last year, the tobacco industry won.

David Orentlicher, in his article The FDA’s Graphic Tobacco Warnings and the First Amendment, writes that the decision is both surprising and not surprising. It’s not surprising “given the Supreme Court’s increased sympathy toward corporations and their First Amendment rights. Regulations of commercial speech often succumb to judicial scrutiny.” It’s surprising because, while the Supreme Court now restricts the government’s power to regulate corporate speech, it has not in the past interfered with the government’s authority when it comes to regulating matters of public health. Evidently, that’s not the case anymore.

The upshot: (emphasis added)

[C]ompanies today are better able to promote their products, and government is less able to promote health than was the case in the past. Ironically, early protection of commercial speech rested in large part on the need to serve consumers’ welfare. In 1976, for example, the Supreme Court struck down a Virginia law that prevented pharmacists from advertising their prices for prescription drugs. The law especially hurt persons of limited means, who were not able to shop around and therefore might not be able to afford their medicines. Today, by contrast, courts are using the First Amendment to the detriment of consumers’ welfare, by invalidating laws that would protect the public health.

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Neoliberalism, tobacco, and public health (1)

This post became much too long, so I’ve divided it into two parts. The first part is mainly about neoliberalism; the second mainly about graphic warnings on cigarette packs (plus smoking among the homeless). When I read, in a recent NEJM article, “The Supreme Court’s increasing sympathy for corporate speech and decreasing deference to public health authorities makes it more difficult for government to protect the public’s health,” my first thought was: What a perfect example of neoliberalism in action.

fda-graphic-warning-labels-i-cause-diseaseNo one would claim that neoliberalism strives for consistency when implementing its ideals. For example, neoliberalism blames individuals for the health consequences of cigarette smoking (“I cause disease”) and at the same time opposes legislation to reduce cigarette consumption (graphic warnings on cigarette packs). When there is a choice to be made, the deciding factor for neoliberalism will be the efficiency with which wealth can be upwardly redistributed.

Personal responsibility

Personal responsibility — including personal responsibility for health — is a fundamental principle of neoliberalism. David Harvey writes on this in the context of neoliberalism and labor: (emphasis added in this and subsequent quotations from Harvey)

[L]abour control and maintenance of a high rate of labour exploitation have been central to neoliberalization all along. The restoration or formation of [elite] class power occurs, as always, at the expense of labour.

It is precisely in such a context of diminished personal resources derived from the job market that the neoliberal determination to transfer all responsibility for well-being back to the individual has doubly deleterious effects. As the state withdraws from welfare provision and diminishes its role in arenas such as health care, public education, and social services, which were once so fundamental to embedded liberalism, it leaves larger and larger segments of the population exposed to impoverishment. The social safety net is reduced to a bare minimum in favour of a system that emphasizes personal responsibility. Personal failure is generally attributed to personal failings, and the victim is all too often blamed.

Personal responsibility for health — fundamental to healthism (a frequent topic on this blog) — serves the interests of neoliberalism in a number of ways. It can be used to justify reduced spending on health care and social services by the state. This is desirable in itself, according to neoliberals, but it also increases consumer spending on health care, which in turn benefits the health care, pharmaceutical, and insurance industries.Read more

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The general health checkup: Its origins, its future

What is a general health checkup? It’s when you visit a doctor not because of an ongoing chronic condition or because you’re concerned about new, unexplained physical or mental symptoms, but because you want a general evaluation of your health. The assumption behind such a visit is that if you do this regularly, you may prevent a future illness.

general-health-checkups

A recent issue of JAMA had two articles on general health checkups. One of them asked the question: What are the benefits and harms of general health checks for adult populations? It summarized a 2012 Cochrane review that addresses this question (it was written by three of the four authors of that review). The review concluded that health checkups were not correlated with fewer deaths (reduced mortality), neither deaths from all causes nor from cancer or cardiovascular disease in particular. Health checkups were associated with more diagnoses, more drug treatments, and possible (but probably infrequent) harm from unnecessary testing, treatment, and labeling.Read more

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Two children visit their doctors: Social class in the USA

Rick Santorum, responding to Obama’s statement that “the middle class in America has really taken it on the chin,” said that he would never, ever, stoop to using the word “class.” (Dorothy Wickenden in The New Yorker)

Sociologist Annette Lareau has done extensive field work that involves unobtrusively inserting herself (or her field-worker assistants) into the homes and daily lives of families (treat us like “the family dog,” she recommends). Her observations have led her to identify a difference in the parenting styles of families from different social classes. Middle-class families practice what she calls concerted cultivation: parents teach their children skills that prepare them to engage successfully with the social institutions of adult, middle-class life. Working class families value natural growth: parents give their children a great deal of unstructured time in which they must use their own creativity to plan and execute their activities.

rich-poor-children-social-inequality

Lareau’s work is described in her book Unequal Childhoods: Class, Race, and Family Life. Originally published in 2003, it was updated for a 2011 edition. It’s a wonderful book. I think of it whenever people argue – as they frequently do in the US – that America is the land of equal opportunity, therefore those who fail to exert themselves sufficiently have only themselves to blame.

I’d like to cite two stories from Lareau’s book that relate to health care.Read more

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What pediatrics can teach us about addressing adult social determinants of health

Attending to the social determinants of health is especially important for children, since children’s experiences – of poverty, poor nutrition, trauma, abuse, neglect, the prenatal environment – can affect physical and mental health for an entire lifetime. As the authors of a recent commentary in JAMA write: “Pediatrics … continues to evolve clinical practice aimed…Read more

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A new blog on the self

I’ve started another blog called Basic research on the self. My intention is to write there about the social and cultural history of the self, aided by insights from sociology, anthropology, philosophy and psychology (especially critical psychology). This is a subject that relates to a number of topics I’ve written about here. A while back…Read more

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A culture of health needs a market for health

determinants-of-health-scaledWhat is population health? Apparently it depends on who you ask. If you ask those with a financial stake in the current health care delivery system, population health means improving the health of patients who currently use (i.e., pay for) the system. You get a different answer if you ask those involved in public health, community development, or social services. They believe “population” should include everyone in the entire geographic community, whether or not those individuals are able to use or benefit from health care services. They also believe “health” should include quality of life and economic well-being – measures that prevent disease in the first place – and not just conditions addressed by the medical model of disease.Read more

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Healthy lifestyles: Social class. A precarious optimism

Social determinants of health. Marmot, WilkinsonLooking back, it’s now obvious that the Lalonde report did initiate a change in our fundamental understanding of the determinants of health – an understanding that is now beginning to flourish. By stressing the influence of non-medical factors on population health, the report made it possible for governments, academics, and foundations to endorse practices outside conventional medical care. Medical practitioners are equally aware that health care by itself cannot secure a population’s health. Following the Lalonde report, politicians, health merchants, and mass media moguls seized on the idea of healthy lifestyles. They tried to convince us that personal responsibility was the primary determinant of health. In the end, however, I am cautiously optimistic that it is not their voices that will prevail.Read more

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Healthy lifestyles: The unfortunate consequences

Healthy lifestyles yoga poseCollectively, increased health consciousness was followed by increased health care costs. The promotion of healthy lifestyles was not the only reason health consciousness increased in the late 20th century. And there were, of course, many other forces at work that increased the costs of health care. But it seems fair to say that the new perspective on health ended up providing opportunities to expand the demand for more medical services. Any hope that individual responsibility for healthy lifestyles would reduce costs – still touted today by some politicians and health care economists — turned out to be a mirage.Read more

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