Medicine, Public Health and Politics

It's official. I'm done with my first week of medical school. Overall, I can say it was definitely less stressful than the first week of college, much less stressful than the first week of high school and not quite as frightening as the first week of junior high, that is until I saw my first histology slides.

The first five weeks of medical school, otherwise known as Block 1, is titled "Becoming a Doctor." We focus on public health and related topics such as biostatistics and epidemiology during this period. We still learn a little basic science during this time, and we also start learning the basic aspects regarding physical diagnosis. The material is fairly straightforward (it's really a review for me so far), but it's very interesting and can make for great discussion.

One of the first interesting topics presented to us this week was the tension between medicine and public health. Generally when you think of the two, they should be related, right? In reality, they're not. Fundamentally speaking, medicine is very individual oriented whereas public health considers a greater population. Medicine takes a biomedical perspective. Public health considers broader determinants of health such as socioeconomic status. You can get rich doing medicine. You'll be broke doing public health.

For me, the fun this week began when our block leader (who happens to be one of my mph advisors), gave us a presentation where he presented data from studies looking at the interface between socioeconomic disparities within a society and associated health outcomes. There is data which shows a greater income disparity within a population, regardless of total net income (wealth) in that society, is correlated with worse health outcomes than would be observed in populations with a more level income distribution. As you can predict and probably know, America tends to have worse health outcomes than pretty much any other industrialized nation since the poverty gap here is quite large. Of course, these data may be potentially misleading when considering the measurements/standards used, but nevertheless, I think we can all agree that there are quite a few health disparities across the spectrum of socioeconomic status.

All was fine and dandy during this presentation, until our block leader brought up an analogy to bring up the point he was trying to make. The poverty gap in this nation is analogous to the difference between first class and economy on an airplane. Those in first class have it made, right? They have a ton of space. Lots of food. Comfort. The works. Those in the back don't have it quite as good. Tall people like me suffer. We may or may not get food (probably no food at all these days given our atrocious economy). We may not get as good of service as we would if we were in first class. We might even resent those sitting in first class because they have it made and we don't. The best way to make the flight fair for everyone would be to eliminate the class system and have one seating section.

But is this really fair? What if you have enough money to pay for the first class seat, don't you deserve it? Really the analogy when extended to healthcare, becomes a political question. I'm sure you've figured what I'm getting at: the concept of a national health care system. See, I don't know if this is really fair for everyone. I believe people should have options. Inequalities are not inequities.

So consider the poverty gap in the US like a room with a very high ceiling. If we want to improve the health of those worse off, why don't we just raise the floor closer to the ceiling? Really, who cares how high the ceiling is. This is how I think about this issue. We need a standard minimum care for individuals in this nation. In theory this is awesome, but how to we pay for it? Now we're talking politics.

It seems like people in America 1.) don't know what universal healthcare is and 2.) are afraid of it. First, universal healthcare does not have to mean socialized medicine. These are two different concepts people. It doesn't mean you'll be waiting in these god-awful lines to get your immunizations. Universal healthcare can merely mean making sure the worst off in our society have access to decent, affordable healthcare for basic needs. Of course, we are all to some extent somewhat afraid of this because we don't know how we're going to pay for it. Dare I say the "T" word....taxes...yeah, scary.

Before I let my political thoughts get in the way of making a coherent post, I can basically tell you that the presentation was quite controversial. I understand what our block leader was saying. You would have to be pretty naive to not admit that our country has serious health issues. Some people in this country are simply getting the shaft. Some people are going bankrupt because they can't keep up with escalating health care costs to manage their chronic conditions.

So what do we do about it? Frankly, I don't know. I wish I did. I understand both sides of the argument. We live in a country that embraces free market capitalism and innovation, and I am proud of that. Access to healthcare, which I have discussed, is an issue. However, what our block leader was getting at was that more upstream issues such as socioeconomic status can be potentially viewed as the root of the problem. Should we do a better job of redistributing income by raising taxes for the well off? Should we extend current tax cuts and continue with supply side economic principles? These are some heavy issues and various people have different opinions.

Politics permeates medicine, and it all starts in med school when we're naive kiddos memorizing histology slides. At Case we have a couple medical organizations on different ends of the political spectrum. There is American Medical Student Association, which supports universal healthcare, and is generally averse to the presence of pharmaceutical companies in teaching hospitals and medical schools. The American Medical Association's medical student chapter is much more conservative. The AMA is a huge physician lobbying group which basically owns congress. They vouch for physician interests and advocate for market based healthcare reform. This past week, AMSA gave us a nice presentation. I'm sure we'll hear from the AMA later during the block.

Frankly it's all overwhelming. I keep questioning myself what my role as a physician is to society as a whole. I know what my duty is to an individual patient, but what about the greater population? I guess it all depends on what you believe in and you perhaps lean politically. I'm still trying to figure things out. I'll let you know when I have some answers.